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WORKS BY Dr. M. PUTNAM JACOBI. 



The Question of Rest for Women during Menstruation. 

Being the Boylston Prize Essay of Harvard University 
for 1876. Third edition. 8vo, cloth, illustrated, $2 00 

" Based on a wide range of observation, experiment, and 
new statistics, the accomplished author subjects her material 
to a searching analysis, and brings forward a series of original 
propositions regarding the sexual accidents of women, admi- 
rably stated and ably defended." — Phila. Med. and Surg. 
Reporter. 

Infant Diet. By A. Jacobi, M.D. Revised, enlarged, and 
adapted for popular use by M. Putnam Jacobi, M.D. 
i2mo, boards 50 cents. 

Hysteria and Other Nervous Affections. A series of 
Essays. 



ESSAYS 



ON 



HYSTERIA, BRAIN-TUMOR 



SOME OTHER CASES OF NERVOUS 
DISEASE 



BY 



MARY PUTNAM JACOBI, M.D. 

AUTHOR OF "the QUESTION OF REST FOR WOMEN DURING MENSTRUATION," ETC., ETC. 







NEW YORK AND LONDON 

G. P. PUTNAM'S SONS 

%\z ^nitbrbocbr ^rws 

1888 



^. 



Is* 



COPYRIGHT BY 

G. P. Putnam's Sons 



Press of 

G. P. Putnam's Sons 

New York 



CONTENTS. 



I. — Some Considerations on Hysteria . . . i 

II. — Tumors of the Brain 8i 

III. — Note on the Special Liability to Loss of Nouns 

in Aphasia 140 

IV. — Case of Nocturnal Rotary Spasm . . .161 

V. — The Prophylaxis of Insanity .... 178 
VI. — Antagonism between Medicines and between 

Remedies and Diseases 195 

VII. — Hysterical Locomotor Ataxia .... 205 

Index 215 



HYSTERIA AND OTHER NEUROLOGICAL 

PAPERS. 



L 

SOME CONSIDERATIONS ON HYSTERIA.^ 

Notwithstanding the voluminous literature which 
exists on hysteria, something always remains to ob- 
serve and describe in it. And this is to be expected 
when it is remembered that hysteria implies disarrange- 
ment of the functions of any part of the nervous 
system — in its four spheres of intelligence, mobility, 
sensibility, and visceral neurility. Every advance in 
our knowledge of these mysterious functions must, 
therefore, lead to some new point of view in regard to 
hysteria, or to mental, motor, sensory, or visceral 
neurosis. Is it possible at the present day to formu- 
late the fundamental condition of hysteria in such a 
way as to bring it into harmony with the facts of the 
hysterical temperament, of the general neurotic diathe- 
sis, of the vaso-motor spasms, of the special, mental, 
motor, and sensory phenomena of hysteria, and of the 
relations of the developed disease to the reproductive 
organs on the one hand, and to moral and social con- 
ditions on the other ? 

It seems to me that we can assert the following to 

^ The nucleus of this paper was read before the Neurological Section of the 
Academy of Medicine, June ii, 1886. 



2 SOME CONSIDERATIONS ON HYSTERIA. 

be the twofold condition fundamental to hysteria : 
There is in it a congenital or acquired deficiency in 
the power of nerve-elements to effect the storage of 
force in nerve-tissues. 

This can only be overcome by increasing the amount 
of stimulus to which these elements are subjected. 
Conversely, the elements of those centres, which are 
subjected to a preponderance of stimulus, will perform 
the function of storage most effectively, and, in so do- 
ing, will acquire preponderance over the others. And 
this is done by the sensory centres of the brain. 

These centres, connected with the nerves of special 
sense and of common sensibility, are, from the begin- 
ning of life, exposed to the most incessant stimulation, 
fom the constant impact upon them of centripetal im- 
pressions. The registration of these impressions is 
attended by chemical synthesis within the cells (Mey- 
nert) by " negative work " (Wundt). Such synthesis 
implies the storage of oxygen into complex chemical 
compounds, in which It becomes latent. These may 
be called force-compounds, because upon their explo- 
sive decomposition depends the liberation of energy, 
or force, the '' positive work." ' 

Thus the synthetic nutritive processes of the central 
nervous tissues are closely associated with their func- 
tional stimulation through the arrival of Impressions 
from the periphery. '' The optic nerve, which resem- 
bles In structure the central white substance, under- 
goes changes within two or three days of extra-uterine 
life, which far exceed those changes which would take 

^ The negative work is the first result of centripetal stimulation of a nerve- 
centre (central galvanization). During it no tangible phenomenon occurs. It 
is followed by the positive work, centrifugal impulse resulting in muscular con- 
traction. Wundt: '* Mechanik du Nerven," 1871. 



SOME CONSIDERATIONS ON HYSTERIA. 3 

place during a much longer period of intra-uterine life. 
This shows most distinctly that the nutrition of central 
nervous tissues is greatly aided by sensory stimuli." 
*' The centripetal nerve-tracts are the keys which start 
the mechanism of the entire central nervous system ; 
and we see that the peripheral nutritive influence is 
indicated by the special order in which nerve-tracts 
acquire their white substance" (Meynert, " Psychiatry," 
Transl. Sachs., pp. 268 and 269, 1885). 

As far as the sensory centres are concerned, there is 
no indication that their storage capacity in hysteria is 
deficient ; indeed, the preponderance of sensation over 
centrifugal force, motor or mental, would lead us to 
infer a relative excess of storage in these centres. But 
the theory of deficient storage of force in hysterics is 
based on their inability, as compared with persons 
soundly organized, to bear fatigue, mental exertion or 
emotion, or privation of food, or fresh air ; peculiarities 
which are noticeable even in persons who, at the time 
of trial, are in good health, with their constitutional 
tendencies latent. 

Exertion, mental or physical, implies nervous dis- 
charge ; the capacity for this is proportioned, partly to 
the amount of force-material previously stored in nerv^e- 
cells, partly to the capacity of these to rapidly store up 
new material, even while discharging-processes are 
going on. Deficiency of storage necessarily accelerates 
the moment when consumption of force-material must 
be complete, unless this can be rapidly renewed — 
hence accelerates the approach of fatigue. But the 
same deficiency in storing processes, which would lower 
the amount of accumulated supply, might be expected 
to render storage during action difficult or impossible. 
The hysteric, therefore, should require more absolute 



4 SOME CONSIDERATIONS ON HYSTERIA. 

rest for recuperation after exertion than is necessary 
for a normal person. The same circumstances would 
render either privation of food or of abundant air- 
supply sooner intolerable. Hence it is the hysteric 
who is most likely to faint In a badly ventilated room. 

The portions of the nervous system whose capacities 
are impugned by these facts, are those which are asso- 
ciated with centrifugal impulses or with the liberation 
of energies in action. These centrifugal energies are 
of two kinds : motor and mental. The stimuli which 
provide for the storage of force-material in the nerve- 
centres concerned in mental and in motor action are 
more indirect than the stimuli of the sensory centres. 
It seems to be the discharge of motor energy, which, 
possibly by emptying the cell of a certain amount of 
material, principally determines the acquisition of new 
material from the blood, and Its storage in forms of 
higher complexity. It is well established that the 
nutrition of the muscular fibre depends largely upon 
muscular action, which involves repeated explosive 
decompositions and elimination of material from stor- 
age cells. In centres of incessant reflex action, this 
stimulus from its ovi^n function may be supplied as 
constantly as is that of the sensory centres. But 
wherever volition is involved there exists the possibil- 
ity of avoiding action and, by so much, of lessening 
the amount of stimulus which should be supplied to the 
motor mechanisms. 

In the cortical motor centres of the brain, according 
to the bold and ingenious hypothesis of Meynert, a 
second form of stimulus exists, derived from the regis- 
tration of impressions during the performance of 
reflex-motor acts by subcortical mechanisms. Of each 
such act an impression or image is said to be registered 



SOME CONSIDERATIONS ON HYSTERIA. 5 

upon the cortical cells connected with the nerves sup- 
plying the contracting muscles. The Impression Is 
called by Meynert an " innervation sensation," and is 
supposed by him to be transmitted to the thalamus 
from nuclei of the tegmentum, which are themselves 
connected v/ith the lenticular body, and from the thala- 
mus to the cortex, by the fibres of the corona radiata. 
The cortical cells are thus rendered " spectators " of 
all reflex acts. The registration of the impression Is 
attended here, as elsewhere, by chemical synthesis, z\ 
^., by the storage of material destined for the future 
elaboration of force. 

The sensory impression which has initiated the 
reflex act Is also registered in the cortex, and, when 
transmitted to other cortical areas associated with that 
which has received this impression. It becomes trans- 
formed into a secondary, that Is, Into an Ideal Impres- 
sion. The revival of such a secondary impression, 
thus the memory of the original sensation, tends to 
revive the Image of the motor act originally associated 
with it, and which has been registered in the motor 
centres. The revival of this Image liberates energy In 
a centrifugal direction, along the fibres of the pyra- 
midal tract to spinal nerves and voluntary muscles. 
This energy, due to intracerebral stimulus. Is said to 
be voluntary ; but it is directed to the same nervo- 
muscular mechanism as had already accomplished 
motor acts of the same form as those now designed, 
I. e.y the subcortical reflex mechanisms/ 

Thus the stimuli to storage In the cortical motor 

^ Meynert, loc. cit., gives a diagram, illustrating this theory. It shows the 
conversion of a reflex movement of vi^ilhd rawing the hand from a candle by 
which it had been burned, into a voluntary movement, determined by recollec- 
tion of the burning sensation acquired on a previous occasion, and itself revived 
by a new sensation — the sight of the candle. 



6 SOME CONSIDERATIONS ON HYSTERIA. 

centres are : ist, the registration of impressions of 
innumerable reflex motor acts, performed involun- 
tarily, and before conscious volition is possible ; 2d, 
the liberation of energy under the influence of intra- 
cerebral impulses associated with memorized and with 
secondary impressions. This latter constitutes the 
performance of voluntary acts, or in other words, is the 
exercise of the positive function of the centre, the 
evolution of its positive work. 

The ''latent areas" of the cortex (Exner), uncon- 
nected with either motor or sensory tracts, continu- 
ally receive, through association-fibres and the gray 
network of the surface, secondary impressions obtained 
by revival of those which had been originally registered 
in the motor and sensory regions. Consciousness is 
gradually built up of masses of such secondary im- 
pressions, and thus is finally traceable to memories of 
the impressions made on the organism by the outside 
world, and of the movements which have been per- 
formed by the organism in direct or indirect response 
to these impressions. It is to be presumed that the 
registration of the secondary impressions is attended 
by chemical synthesis in the registering cells, similar 
to those which accompany the registration of primary 
impressions. 

And further, we must infer from the foregoing con- 
siderations, that each ganglionic cell or area of the 
cortex acts both as a receiving and as a discharging 
centre. In registering sensory, motor, or revived 
(ideal) impressions, its protoplasm performs a work of 
chemical synthesis. In transmitting impressions, either 
in a centrifugal or in an intracerebral direction, the 
same protoplasm effects a chemical decomposition, 
whereby energy is liberated. 



SOME CONSIDERATIONS ON HYSTERIA. / 

The same reasons which compel us to infer that, in 
motor areas, this liberation of energy acts as an in- 
direct Stimulus to storage, apply to all the areas of the 
cortex, to the latent (mental ?), as well as the rest. 
Thus the intracerebral circulation of impressions is 
the stimulus, although an indirect one, upon which 
force-storage in the cortex depends, and for those 
cortical regions which receive no direct stimulus 
through centripetal nerves, and no indirect stimulus 
through motor nerves, this intracerebral circulation is 
the only functional stimulus. When an impression is 
received on a ganglionic cell, its registration directly 
effects chemical synthesis ; when an impression is liber- 
ated, its transmission indirectly does the same thing. 

The smaller the amount of force-material stored up 
from the blood under the influence of the centripetal 
stimulus, the smaller can be the amount of work 
evolved in the centrifugal direction in a given unit of 
time. If the amount is increased, the period of its 
evolution is shortened-—/, e., the advent of unconquer- 
able fatigue is accelerated. Conversely, when we note 
the speedy advent of fatigue, as in children, women, 
and hysterics, we must infer that the storage of force- 
material has been less than in cases where the period 
of exertion can be prolonged. The wide diffusion of 
the " hysterical temperament " in women is correlated 
with their generally lesser capacity for the storage of 
force, which may, nevertheless, remain within physio- 
logical limits. If the deficiency fall below these limits, 
it results in the altogether morbid limitations of hyste- 
ria. And, while there are many women whose capacity 
for force-storage — as measured by their capacity for 
exertion — considerably transcends the average of their 
sex, and even reaches the masculine average, so there 



8 SOME CONSIDERATIONS ON HYSTERIA. 

are not a few men whose capacity in this respect falls 
to the level of hysteria, and v/ho exhibit hysterical 
phenomena in consequence/ 

The sensory centres of the brain in hysterics are 
exposed to two different kinds of derangement — cor- 
responding to two opposite phenomena — anaesthesia 
and pain. In the first, the registering power of the 
centre is so diminished as to fall below the level of con- 
sciousness ; and this either by privation of blood-sup- 
ply, through vaso-motor spasm, or by direct depression 
of protoplasmic energy to appropriate material from 
that. The latter case enters completely into the gen- 
eral theory of depressed storage-power in hysterical 
nerve-tissues. 

In the innumerable forms of hysterical hyperaesthe- 
sia, an opposite process must occur. The centripetal 
stimulus remaining the same, it would seem as if a 
larger amount of chemical syntheses were effected in 
the centre under its influence. When a sensory centre 
is subjected to an excess of stimulus — through a 
violent centripetal irritation — it is known that the 
functions of other nerve-centres may be transiently 
arrested or inhibited. We may ask whether the same 
inhibition of other centres is not liable to occur when 
in the centre there is an excess of reaction to a normal 
stimulus ? 

Inhibition has been explained as a phenomenon of 
interference between the waves of molecular movement 
transmitted along nerve-fibres ; interference analo- 
gous to that, which, when occurring between waves 

^ Charcot remarks that male hysteria has become rather a topic of the day, 
" sujet k I'ordre du jour." He cites a thesis by Klim, containing sixty cases, 
and a monograph by Batault, containing two hundred and eighteen. See Gail- 
lard's Journal, June, 1886. I have seen several such cases. 



SOME CONSIDERATIONS ON HYSTERIA. 9 

of light causes darkness, and between waves of sound 
causes silence.^ 

In the nerve-tissues, if these waves of molecular 
movement coincide, the intensity of the movement is 
increased. But if one wave be retarded out of the 
normal rhythm, so that its crest fall within the trough 
of the other, this second wave will be antagonized, 
and the action of the nerve-centre from which it 
emanates will, therefore, be apparently diminished. In 
reality it is not the activity of the centre which is 
diminished, but the effect of that activity. 

This is the explanation of inhibition given by Claude 
Bernard for the chorda tympani, by Ranvier for the 
vagus, by Lauder Brunton and by Wundt for the phe- 
nomenon of inhibition in general. In accord with this 
conception, we may suppose that when in a nerve 
mass, as the sensory centres of the brain, the negative 
work of intra-molecular synthesis and storage becomes 
greatly increased, the wave of movement constituting 
the positive work or centrifugal impulse may become 
retarded, and this disarrangement of normal rhythm 
may suffice to make it interfere with and antagonize 
the molecular waves coming from other cortical areas. 
These latter, therefore, would be inhibited, as an 
indirect consequence of the surcharge of sensory 
centres. 

The violent centripetal irritations of sensory centres 
which are accompanied with pain, always tend to arrest 
motor and mental action. Their action is not limited 
to the fore-brain ; the arrest of the heart's action is a 
well-known phenomenon of sensory inhibition. Nor 

^Brunton: "Pharmacol.," p. 200; Ranvier: " Lecons d'anat. gen.," 
1877-78, p. 170. CI. Bernard : "Rapport sur le progres de la phys.," 1867, 
p. 67. Wundt : " Allgemeine Nerven Pbysiologie." 



lO SOME CONSIDERATIONS ON HYSTERIA. 

is it probable that the irritation expends itself exclu- 
sively upon the sensory centres of the cortex, but is 
rather distributed throughout all the receiving stations 
of the cerebro-spinal axis. Now, when under the in- 
fluence of a normal stimulus, the cortical centres have 
acquired the habit of registering impressions abnor- 
mally and excessively, as is shown by the patient feel- 
ing pain entirely out of proportion to the magnitude 
of the irritations, we must believe that the work of 
chemical synthesis excited in the sensory centres, is 
also excessive. It should, or at least may follow, that 
the waves of molecular movement transmitting im- 
pression in an intracerebral direction become retarded, 
and thus " interfere " with waves coming from other 
cortical areas. Then, though to a less degree than 
with violent pain of peripheric origin, the play of in- 
tracerebal associations and impulses, and their ultimate 
convergence upon motor (volitional) acts, will be 
interfered with. Hysterical ''paralysis of volition" 
should be the necessary correlative of hysterical 
hyperaesthesia. 

Many facts indicate that the inhibition of one nerve- 
centre by another is powerful in proportion as the stor- 
age of force in the first exceeds that of the second. 
The feeble control of the vagus centre over the heart 
in rabbits, the feeble control of the cortex over the 
subcortical motor (convulsive) centres in young chil- 
dren, negatively illustrates this law. 

In accordance with this, the inhibition of the non- 
sensory cortical areas will be easy, in proportion to an 
habitual deficiency in the storage power inherent in 
their tissues. And since the active function of these 
areas in motility, volition, and thought, has been 
shown to furnish an important though indirect part of 



SOME CONSIDERATIONS ON HYSTERIA. II 

the stimulus upon which this force-storage depends, 
every thing which diminishes such activity, diminishes 
the power of resistance of these parts of the cortex to 
the inhibitory influence of sensory areas — renders the 
latter^ if we may so express it, more and more tyran- 
nous/ 

It is generally admitted that activity of thought 
and of motion tends in some way to blunt sensation. 
We can most clearly represent this fact to ourselves 
as implying that, during such centrifugal activity, cur- 
rents of molecular movement set in from the sensory 
centres, involving liberation of energy from them and 
chemical decomposition in them — thus elimination of 
material that had been previously stored up, perhaps 
in excess. In the primary reflex acts the current of 
impression always passes from the sensory toward the 
motor centre. But, as Meynert observes, in the brain, 
impressions can certainly traverse fibres in both direc- 
tions ; and as the impulse to voluntary movement does 
not come from the areas registering the primary sen- 
sation, but from others which have become associated 
with them, it is perfectly in order to suppose that the 
intracerebral discharge of the sensory areas is often 
initiated by the play of molecular movements in the 
mental m-Otor regions. And this brings the argument 
round to its starting-point, and suggests that one way 

^According to Ebner and Munk, the sensory areas of the fore-brain are not 
limited to those portions of the cortex which receive the fasciculus from the 
"carrefour sensitive," but extend beyond these until they cover all the motor 
zones as well. It seems not impossible that at least many areas, even many 
ganglionic cells, should be regarded as sensito-motor, and this especially if the 
fundamental function of nerve-elements be accepted as "sensitiveness." But 
the facts, as at present understood, seem to indicate a frequent, though not uni- 
versal, commingling of sensory and motor elements rather than an identity of 
these in function. The schema of sensory inhibition stated in the text must, of 
course, be provisional. 



12 SOME CONSIDERATIONS ON HYSTERIA. 

in which the sensory centres may become hyperexcit- 
able, through excess of storage material, is through 
the lessened discharge of these centres when the play 
of centrifugal activities is defective. It is certain that 
the sensory centred of the cortex are capable of con- 
tinuing their functions of registration almost indefi- 
nitely, even in the exaggerations of pain, while the 
exercise of either active thought or mobility has quite 
a limited duration. 

The foregoing considerations indicate that the fol- 
lowing series of conditions succeed each other in the 
cortex of the hysterical brain : i. A diffused deficiency 
in storage power ; deficiency shared more or less with 
other nerve-tissues, and usually congenital, but some- 
times acquired. 2. Nevertheless, effecting of abun- 
dant storage in the sensory centres, under the per- 
manent, and thus relatively excessive stimulus 
of centripetal impressions. 3. Deficient centrifugal 
activities, mental and motor, or exhaustion of 
mental and motor areas by exertion performed with 
inadequate storage material. 4. Deficient discharge 
of sensory centres, which continue to store material 
under the stimulus of centripetal impressions, but fail 
to decompose and eliminate this sufficiently when cen- 
trifugal movements diminish in activity. 5. Hyperex- 
citability of the sensitive centres, which contain an 
excess of force-material produced during registration 
of impressions, and not broken up by their transmis- 
sion. 6. Tendency on the part of these surcharged 
sensory centres to inhibit the activities of the rest of 
the fore-brain. 

The phenomenon of mental inhibition, resulting in 
inability for mental exertion, is extremely common in 
hysteria. It is often described as ** causeless mental 



SOME CONSIDERATIONS ON HYSTERIA. 1 3 

depression," as " wilful hysterical indolence," or as 
" brain exhaustion." I have not found the suggestion 
anywhere, that the depressive mental phenomena of 
hysteria depend upon functional inhibition of the 
thought-areas of the brain. Yet this view seems to me 
the true one, and alone consonant with all the facts 
of the case. I have often noticed this condition 
in uterine disease, where it persists until this is cured. 
It is not by any means always associated with pains„ 
either in the pelvis — the then focus of irritation — or 
in the head. After the foregoing analysis it may be 
inferred that, in these cases, impressions have been 
generated on a diseased endometrium, or among pel- 
vic nerves, which, though not giving rise to local pain, 
may, when transmitted to the sensory centres of the 
cortex, so overexcite them that they inhibit the remain- 
ing cortical areas. 

The following case offers a curious form of cerebral 
inhibition : 

Case I. — Unmarried woman, a teacher. Subject for several 
years to attacks of transient amblyopia in the left eye, coming on 
many times a day, and lasting from a few seconds to a minute or 
two. These attacks had been diagnosed by two competent oculists 
as "epilepsy of the retina." During a year before consultation 
the patient was also subject to nervous attacks, in which con- 
sciousness seemed to be, not abolished, but perverted for a while. 
The condition is imperfectly described by the patient, who can 
only say that " every thing seems strange," that people do not 
seem to be the same ; that she looks very badly to them, and has 
an inexplicable but profound consciousness of distress. This con- 
dition may last fifteen minutes, half an hour, or longer. Exami- 
nation discovered marked prolapsus of the uterus, so that the cer- 
vix came just to the introitus, and apparently rubbed upon the 
labiae minorge. There were no local symptoms of the prolapsus. 
The uterus, which was structurally apparently healthy, was 
replaced by a cup-pessary, and the cerebral attacks immedi- 



14 SOME CONSIDERATIONS ON HYSTERIA. 

ately and permanently disappeared. The ocular attacks persisted. 
The entire persistence of consciousness during the attacks 
exclude, I should think, the diagnosis of general epilepsy. 

These attacks seem to me to illustrate, though In a 
peculiar form, and on a transient and intermittent 
scale, the cerebral inhibition that is so common and 
so distressing in hysteria, perhaps especially in that of 
pelvic origin. 

Such inhibition, I would suggest, is the real basis of 
the mental symptoms, which result, not from excess of 
mental exertion, but from peripheric irritations in pre- 
disposed persons. 

The sense of mental inability is usually attended 
with psychic pain, and the latter is sometimes so pre- 
dominant that the former is not complained of. 
Psychic pain, if we accept Meynert's exposition of it, 
is a direct consequence of cortical inhibition.' What- 
ever interferes with the free diffusion of functional 
activities throughout the cortex, and with the local- 
ized hyperaemias attendant upon these, occasions the 
** hampered mood," which expresses itself as mental 
distress, or psychic pain. The immediate mechanism 
of this is the same, whether the cause be physical — 
i, c, hysterical — or moral — i, e., objectively justified 
by events. Meynert thus describes the latter form of 
inhibition : 

" The news of the death of a person who was bound up with a 
good portion of our thoughts, whose image would be frequently 
revived in our brain by the most manifold associations, and which, 
when presented to the brain, would arouse all sort of secondary 
presentations and pleasurable emotions — such news, we repeat, 
would cause inhibition of all these associations ; and the place of 
easily excited associations will be usurped by others not yet easily 
transmitted. Inhibition is attended by emotion and psychical 
pain."^ 

' Loc. cit., p. 193. * Loc. cit., p. 103. 



SOME CONSIDERATIONS ON HYSTERIA. 1 5 

According to the same author a second condition 
exists, which must constantly tend to increase both 
psychic pain and mental inability whenever cortical 
activity is diminished or inhibited. 

During the functional activity of the cortex, or of 
any segment of it — and it is probably never active 
throughout its whole extent at once — the vaso-motor 
nerves of the arterioles going to that segment are in- 
hibited, the blood-vessels consequently dilated, and at 
the same time a direct attractive force is exercised on 
the blood-current by the chemical processes which are 
quickened in the ganglionic cells. As a consequence 
of this combined effect, a larger current of blood is 
carried to the active tissue. Conversely, when the 
cortex ceases to be active, as in sleep, or from being 
itself inhibited, or under any other influence, the vaso- 
motor tonus of the blood-vessels is resumed, the 
blood-vessels contract, the cortical tissue becomes 
relatively deprived of blood — anaemic, or, to use Mey- 
nert's expression, dyspnoeic. This condition again 
tends to diminish the power of functional activity in 
the cortical segment or segments to which the con- 
tracted arteries are distributed. 

The foregoing considerations may explain the phe- 
nomena of mental depression (inability for exertion, 
psychic pain) both in grief and hysteria. In the for- 
mer the activity of more or less extensive areas of the 
cortex is directly arrested by destruction of the objects 
and associations which call this into play. In the 
latter the same activity is inhibited by the excessive 
activity of the sensory areas. In both cases the dimi- 
nution of functional activity in the ganglionic cells of 
the cortex is followed by an excess of activity in the 
subcortical vaso-motor centres released from cortical 



1 6 SOME CONSIDERATIONS ON HYSTERIA. 

control. Hence, in the corresponding segments of 
the cortex must follow localized anaemias, which tend 
still further to hamper the functional activity of these 
segments. The greater and more unimpeded the 
functional activity of the cortex, the more widely 
diffused the attendant hypersemias, the more intense 
is the consciousness of physical well-being or happi- 
ness. The unimpeded diffusion of intracerebral im- 
pressions irresistibly suggests a correlatively facile 
diffusion of desire and activity over all impediments 
in the outside world ; consciousness is permanently 
triumphant. In the contrary case the arrest of cere- 
bral activities suggests as irresistibly oppression, de- 
feat, humiliation, disaster in external events ; imposes 
subjectively the depressing emotions of mortification, 
distrust, and apprehension — the depression of spirits 
which is unconquerable, even when the patients them- 
selves recognize its objective groundlessness. '' I have 
every thing to live for, but I am perfectly wretched," 
is a common remark. '' I know I am better, because 
I can now look at that undertaker s shop on the cor- 
ner without feeling ready to burst into tears," remarked 
one patient to me. 

This depression often reaches its maximum during 
pregnancy, when hysterical women often say they will 
'* go crazy," and not infrequently commit abortion, only 
to rid themselves of this subjective misery. 

When the personality is so completely invaded that 
the patient does not recognize the groundlessness of 
her mental suffering, the case becomes complicated by 
her endless misconceptions of her social relations. A 
(relatively mild) form of the delirium of persecution is 
extremely common among hysterics, even those who 
never exhibit the severer physical phenomena of the 



SOME CONSIDERATIONS ON HYSTERIA. 1/ 

disease. The harmonious maintenance of social rela- 
tions seems to demand the self-consciousness of an 
energetic and adequate personality. Cortical inhibi- 
tion, which weakens this consciousness and fills it with 
self-distrust, almost necessarily engenders suspicion of 
others. 

In the typical hysterical temperament egotism is a 
noticeable feature. In hysterics of small minds this 
may suffice to exclude all interest in external objects. 
In larger and more cultivated minds such interests are 
not excluded, but there is an extraordinar>^ tendency 
to look at them only in their relation to the person, 
and only in so far as they can be made material to sub- 
serve his or her vanity and amour-propre. This remark- 
able tendency is clearly traceable to the predominance 
of the sensory functions of the fore-brain. Nerve- 
currents constantly direct attention toward the goal to 
which they flow. For centripetal sensory impressions 
this is the receiving organism ; for centrifugal, it is the 
world upon which that organism expends its energies. 
Exaggeration of the sensory functions constantly 
tends, therefore, to exalt the consciousness of the per- 
sonality over that of the external world. Activity of 
the voluntary functions constantly tends to divert 
attention from the personality to the external world. 
When this habit is firmly established, feelings, as well 
as actions, direct attention to the external world in 
which they originate ; the individual constantly be- 
comes more and more objective. On the other hand, 
the person who, in the presence of interesting or im- 
pressive events, is only preoccupied with the emotions 
or sensations they may have engendered in himself, is 
distinctly marked with the hysterical stigma, even 
though, which is rare, no other sign of it ever appear. 



1 8 SOME CONSIDERATIONS ON HYSTERIA. 

One curious result of the psychic aspect of hysteria 
is the manifold way in which it checks the develop- 
ment of the maternal instinct. The frequency of uter- 
ine disease in hysterics — the frequency with which 
their reproductive organs are imperfectly developed, 
the frequency of accidental abortion — entails sterility 
in an immense number of cases from physical causes. 
When hysterical women bear children, they are usu- 
ally unable to nurse them. In cases where there is no 
physical impediment to conception, this is often pur- 
posely avoided from mere moral perversity. The 
patients profess to hate children, are in despair if they 
become pregnant, and, as already noted, not infre- 
quently commit abortion, under the influence of the 
intense mental depression to which a pregnancy sub- 
jects them. When such women nevertheless have 
children, the hysteria, if not too profound, may be 
cured. But not infrequently the defect in maternal 
instinct persists, and the lives of the children are made 
wretched by the ceaseless exactions, and even increas- 
ing selfishness, of the hysterical mother — personal 
selfishness which Is In unnatural contradiction to the 
profounder maternal egotism which Is natural. These 
conditions are no more universal, or all combined In one 
person, than are any other symptoms of hysteria. Those 
women who are sterile from physical incompetence 
are often tormented all their lives by the longing of 
unsatisfied maternal instincts. Many hysterical women 
do make devoted, though rarely judicious mothers. 
But if not for one cause, then for another, the net re- 
sult is a great diminution of complete reproductive 
capacity In hysterics.^ 

' The classical notion that sexual impulses are particularly strong in hysterics 
is certainly erroneous. Both physically and morally, these are often either sin- 



SOME CONSIDERATIONS ON HYSTERIA. I9 

The bearing of children impHes the Hberation, on 
an immense scale, of centrifugal energies, mental and 
motor. It is the type of an action — correlating, cor- 
recting, and balancing — a feeling, emotion, and pas- 
sion. From a philosophical point of view, therefore, 
the sterility or the deficient maternal instinct of hys- 
terics belongs to the same class of conditions as have 
been already described, and in all of which there is 
deficiency of motor (centrifugal) force, with conserva- 
tion of sensory (centripetal) function. 

The physical sterility, when congenital and not ac- 
quired, allies hysteria, even when remotely, with the 
neuroses of degeneration. What I have termed the 
moral sterility, which, in one way or another, results in 
perversions of the maternal instinct, can be traced to 
the same preponderance of sensory functions, with 
exaltation of the narrowest nucleus of the ego, that, 
namely, which is constitued by the limits of the phys- 
ical organism. The normal maternal instinct implies 
one of the first and always the most powerful enlarge- 
ment of this nucleus, so as to embrace the offspring 
within the pale of self-consciousness. Failure of this 
instinct implies a most unnatural narrowing of the 
range of life within the sensory or purely personal 
sphere. 

Most important, both for diagnosis and for justice, 
is it to recognize that the mental and moral defects 
which result from the conditions described are by no 
means always present. To many hysterics may be 
applied the phrase reserved by Clifford Albutt for 

gularly deficient or singularly perverted, the latter trait constituting one of the 
first links with insanity. The peculiar whims in these respects of hysterical 
women often add to their tendencies to sterility by leading them to avoid mar- 
riage, Moliere has drawn a truthful picture of the refined hysteric in " Les 
Precieuses." 



20 SOME CONSIDERATIONS ON HYSTERIA. 

*' neurasthenics," whom he would distinguish from 
them, — "they are the salt of the earth."' 

Just as marked intellectual ability, and even genius, 
is quite possible in hysterics,^ so may the most amiable, 
unselfish, and affectionate character be not infrequently 
found among them. These facts simply mean that 
the organic tendency, though existing, has been 
counteracted, either by a development of cortical 
tissue considerable enough, and endowed with suffi- 
ciently abundant associations, to resist complete inhi- 
bition in mental spheres ; or else by the educational 
direction given to the formation of associations, and 
to habits of action, which enables these to offer 
resistance to sensory inhibition. 

Between the cases where mental depression is caused 
by sensory inhibition and those where it is due to the 
inhibition of associated ideal impressions, lie the 
others, where a real moral cause permanently deranges 
the mental mechanisms, and the affected persons 
become hysterical from grief or shock. These cases 
are in many respects analogous to cases of chorea 
from fright. An impression is made upon certain 
cortical areas so . powerfully that they remain over- 
excited, and inhibit the activity of the rest. In chorea 
it is the motor regions of the cortex which are chiefly 
affected by the inhibition. In adult hysteria it is all 
of the fore-brain which is concerned in thought or 
volition ; the convergence of intracerebral impressions 
upon centrifugal tracts is impeded, so that thought and 
volition are held in abeyance. Sometimes even por- 

^ Visceral Neuroses. 

2 Madame de Stael iudulged in the most violent outbursts of hysterical 
emotion ; Charlotte Bronte suffered from prolonged hysterical hypochondria, 
probably due to endometritis ; George Eliot was the victim of hysterical head- 
.aches, and probably of other forms of the disease. 



SOME CONSIDERATIONS ON HYSTERIA. 21 

tions of the sensory centres are involved in the inhi- 
bition ; the patient suffers amblyopia, or localized 
anaesthesia of some sphere of common sensibility. 
More often the sensory centres remain intact amidst 
the depression of all the rest, and the patient becomes 
the victim of agonizing pains — though in the absence 
of any peripheric cause for pain. These are the pains 
of cerebral origin, which are typically hysterical. 

In suspensive or cataleptic hysteria, which is more 
frequently induced by moral than by other causes, the 
entire fore-brain has lost its susceptibility to stimuli ; 
hence has lost its power of either storing force or of 
liberating energy. The complete suspension of func- 
tion in these cases is only the maximum exaggeration 
of the condition which is fundamentally characteristic 
of all forms of hysteria. 

In these suspensive forms of hysteria the perversion 
of oxidation processes is also exaggerated to a maxi- 
mum. The amount of urine and of urea is greatly 
diminished ; the latter may fall from twenty to two 
grammes a day.' The phosphoric acid is also dimin- 
ished. Empereur has measured the absorption of 
oxygen and elimination of carbonic acid in this class 
of patients, and has found both greatly diminished. 
In one case the movement of disassimilation, as thus 
estimated, was twenty-four times less than normal. 
According to the same author, cataleptics absorbed 
more oxygen than they eliminate carbonic acid, al- 
though both processes are greatly diminished in 
intensity. 

The extent of these chemical alterations indicate 
that the depression of function extends beyond the 
fore-brain, and probably involves the entire nervous 

' Fabre : De I'Hysterie Viscerale. 



22 SOME CONSIDERATIONS ON HYSTERIA. 

system ; hence affects all the nutritive processes un- 
der its control. Since the main object of the absorp- 
tion of food, of the circulation of albumen and of 
its oxidation, is the maintenance of energy in the 
nervo-muscular system, the suspension of such energy 
is naturally followed by depression to the lowest 
point of nutritive absorptions and oxidations. 

In chloro-ansemia, the peculiar neurosis of puberty, 
which is so closely allied to hysteria and so frequently 
passes into it, the characteristic alteration of the 
blood has been shown to be a diminution not, in the 
number of the blood-corpuscles, but in the haemoglobin 
they contain (Gowers). There is, then, in these 
elements, a deficiency in the power of fixing or storing 
oxygen, which, demonstrated in them, may serve as an 
index to a similar (probable) deficiency in the elements 
of the nerve-tissues. Between chloro-anaemia, the 
mildest form of the disorder, and suspensive hysteria, 
the most complete and severe, stretches an uninter- 
rupted series of morbid states. 

The existence of psychic symptoms in a case of 
hysteria, or in the history of the case, is admitted to 
establish that the fore-brain is then involved in the 
disease. But in the cases where these are inconspic- 
uous, the participation of the brain is less readily 
seen, and still less does it appear self-evident that 
non-psychical symptoms are to be referred to the 
brain. Thus, though a few writers define hysteria as 
a disease of the brain,' there are more who call it a 
diffuse cerebro-spinal neurosis, or a neurosis of the 
vaso-motor system. 

The problem should be thus stated : Given a group 
of sensory, motor, or vaso-motor phenomena, to 

^ Jolly : Ziemssen's Handbook, art. Hysteria. 



SOME CONSIDERATIONS ON HYSTERIA. 23 

decide whether these originate in disorders of the 
medullary or spinal nerve-centres, or whether they are 
due directly or indirectly to disorders of the cerebral 
cortex. 

Now, it can be shown, I think, first, that in a large 
group of cases the phenomena in question either are 
attended by some mental symptoms, or that these 
have occurred in the history of the patient previous 
to the manifestations of the physical symptoms ; 
second, that the character of the "physical " symptoms 
themselves are explicable when referred to the brain, 
but not when referred, finally, to lower centres. 

It is the neuroses which present these two funda- 
mental characters which may properly be called hys- 
terical ; and are so even when they have themselves 
been caused by organic disease in a thoracic or ab- 
dominal viscus, or are associated with organic disease 
of the nerve-centres themselves. 

Neuroses which really originate in medullary-spinal 
centres, though often presenting symptoms which re- 
semble those of hysteria, and sometimes occurring 
independent of hysteria, in persons of hysterical 
constitution, require to be carefully distinguished from 
the hysterical neurosis itself. 

The principal non-psychical phenomena of hysteria 
are, in the motor sphere, paralysis and convulsion ; in 
the sensory sphere, anaesthesia and pain ; in the visceral 
sphere, numerous derangements, traceable to vaso- 
motor spasm or the spasmodic contraction of un- 
striped muscular fibre. 

That hysterical paralysis is an affection of the cor- 
tical motor centres is generally conceded, chiefly on 
account of the marked influence often seen to be 
exercised over it by mental impressions. But this is 



24 SOME CONSIDERATIONS ON HYSTERIA. 

also indicated by the (frequently) monoplegic charac- 
ter of the paralysis, and by the preservation of nutri- 
tion and faradic contractility in the affected muscles. 
The second character, identical with that of organic 
cerebral paralysis, tends to exclude the ganglionic 
centres of the spinal cord, and to establish the proba- 
bility of the cerebral origin of the disease. The 
monoplegic form of paralysis is as characteristic for 
the cortex in functional derangement as in organic 
lesion. 

Such functional cortical paralysis represents the 
maximum degree of inhibition of the cortical motor 
areas — of which some degree exists in the majority of 
all cases of hysteria. When the paralysis involves 
the nerves of the lower extremity, and utero-ovarian 
disease coincides, the paralysis is often called reflex, 
and supposed to be in some way connected with reflex 
spinal arcs.^ 

But, first, there is no physiological experiment 
which exhibits paralysis resulting from irritation ^ of 
the sensory part of a reflex arc, but only excess of 
muscular contraction — spasm. 

Second, cases of paralysis without pelvic symptoms, 
or ascertainable lesion, entirely resemble those in 
which these coexist. 

Third, paralyses of distant nerves — as of the 
laryngeal, or paresis of the nerves of the throat — 
are very common substitutes for paraplegic paralysis, 
and certainly lie beyond the pelvic reflex arcs. 

^ Brown-Sequard assumed a vaso-motor spasm in the motor ganglia of the 
cord, dependent on sensory irritation. Leyden has attacked the vaso-motor 
reflex theory, substituting that of an a=;cending neuritis, on the testimony of 
two cases, with autopsies. 

^ Brown-Sequard's experiments consisted in hemi-sections of the cord, which 
were followed by hyperaesthesia of the same side due to vaso-motor paralysis. 



SOME CONSIDERATIONS ON HYSTERIA. 25 

The following cases are illustrations : 

Case II.' — Intensely chloro-ansemic girl of twenty-two. Ova- 
rian hyperaesthesia for a year, without tangible lesion of uterus 
or ovaries. Then suddenly, incomplete paraplegia lasting twenty 
four hours. Recovery ; relapse a few weeks later. Paraplegia 
remained incomplete for several months. Patient began to suffer 
from severe dysmenorrhoea ; pelvic pains gradually encroaching 
on intermenstrual period, until life was rendered perfectly wretched 
by them. Ovary found prolapsed. Paraplegia became so com- 
plete that patient could not move toes, and remained so for seven 
years. Then oophorectomy was performed by Dr. Munde, for 
relief of dysmenorrhoea ; and with no hope of affecting paralysis. 
In ten days after the operation, patient could move the toes ; in 
a month, had quite recovered power of walking. Ovaries, to 
naked eye, said to have been healthy. 

Case III. — Girl engaged in factory work. Incomplete para- 
plegia, with fixed right ovarian hyperaesthesia ; no dysmenor- 
rhoea ; uterus retroverted ; otherwise healthy. Permanent 
replacement of uterus had no effect ; galvanism at times entirely- 
restored power of walking ; this again lost. 

Case IV.^ — This case was diagnosed as true locomotor ataxia 
in several hospitals, but the ataxic symptoms entirely disappeared 
after an operation for laceration of the cervix. 

Case V. — Married woman, aged forty. Subject for many 
years to altercations with husband ; loss of power of walking 
— /. e., experienced so much pain in walking that she considered 
herself unable to walk, and took to bed for two years. No 
uterine disease at all. Recovery rapid after positive diagnosis of 
hysterical nature of " paralysis." 

Case VI. — Woman, aged thirty-five. Subject for five years to 
uterine hemorrhages, associated for a year or two with intermittent 
aphonia. Uterine fibroid sessile in fundus. Removal ; arrest of 
hemorrhages, but attacks of aphonia continued to recur for a 
long time. 

These cases, varying superficially, resemble each 
Other in the preservation of nutrition and faradic 

^ The termination of this case was observed and reported by Dr Munde in 
the New England Medical Monthly. 

^ Reported by me in the Archives of Medicine as hysterical locomotor 
ataxia. 



26 SOME CONSIDERATIONS ON HYSTERIA. 

contractility; indeed, in the absence of all objective 
symptoms, and the summing up of the disease in the 
single condition — inability of the will to determine 
the contraction of certain muscles. To what could 
this be due but to depression, or inhibition of the func- 
tions of the cortical motor centres in liberating energy 
in motor tracts in response to intracerebral stimulus ? 
In Case IV. alone did the inhibition of the cortical 
centres seem to be associated with peripheric irritation, 
for in Case II. the ovaries were reported as normal, 
and the operation seems to have been successful 
through removing the stimuli of the menstrual pro- 
cesses from hyperexcitable sensory centres. The 
sensations of fatigue, of which hysterics complain so 
much and so bitterly, often represent a minor degree 
of inhibition of cortical motor centres. It makes no 
difference how perfectly may be accomplished nervo- 
muscular functions through the body, if the only 
conscious spectator of these — the fore-brain — registers 
them awry. 

When the patient is anaemic or cachectic, there is 
certainly often reason to suppose that the reparative 
nutrition of the entire nervo-muscular system is 
impaired. But this is not the case in really hysterical 
fatigue, which, though just as real to the consciousness 
of the patient, may coincide with every sign of excel- 
lent general nutrition. The intimate process of the 
phenomenon of fatigue is to-day supposed to be the 
accumulation within nerve- or muscle-tissues of the 
waste chemical products of previous exertion. The 
elimination of these acid excretae is often interfered 
with in lithaemia, from the diminished alkalinity of 
the blood bathing the cells, and into which the acid 
substances should osmose largely in proportion to 



SOME CONSIDERATIONS ON HYSTERIA. 27 

that alkalinity,' Hence the frequent muscular pains, 
aching-, and weariness ; and, when the condition extends 
to the fore-brain, the frequent clinical combination of 
lithaemia and hysteria. High tension in veins and in 
capillaries must also interfere with exosmosis from 
cells ; hence the low arterial tension of anaemia, which 
constantly tends to increase venous tension, interferes 
with the elimination of waste, and tends to prolong 
fatigue, as frequently happens in anaemic hysteria. 
But in the brain exist special mechanisms for the 
removal of waste, which are correlated with the special 
necessity for prompt and complete removal. And 
that it is this mechanism which is principally deranged 
in the fatigue of hysteria is shown, I think, by the 
peculiarities of sleep in hysterical persons, and their 
habitual increase of fatigue immediately after the 
period which should, normally, restore them. The 
fatigue-products of the brain, if not of all nervo-mus- 
cular tissues, are principally eliminated during sleep. 
This is the reason that the morning urine contains, as 
Mandel has demonstrated, larger amounts of phos- 
phoric acid than that formed during the day. During 
sleep, both the breaking down of waste products into 
their elements and the elimination of these from nerve- 
tissue occur more extensively. Among^nerve-tissues 
it should be principally those of the fore-brain which 
is thus refreshed by sleep, since its activity is much 
the most completely suspended. Now, it is quite 
characteristic of persons in whom hysteria exists, or is 
imminent, that they wake in the morning with a sense 
of physical fatigue, or of mental depression or irrita- 
bility. Schopenhauer thinks it is one among many 
proofs of the theory of pessimism, that the happiest 

' See Ranke : Lebens bedingungen der Nerven. 



28 SOME CONSIDERATIONS ON HYSTERIA. 

moment of the happiest Hfe is that of falHng asleep, 
and the unhappiest moment of unhappiness is that of 
first awakening. This is true when legitimate causes 
for mental depression exist, and is also true when 
their influence is simulated in hysteria. 

In the nervous system, and especially in the brain, the 
waste products do not pass directly into capillaries, but 
into the lymphatic sheaths surrounding the arteries. 
The circulation of the lymph-current, and its passage 
from the perivascular to the subarachnoid spaces, is 
regulated by the pulsations of the brain, or its varia- 
tions in volume, by which the lymph-spaces are rhyth- 
mically compressed. The brain-pulsation is composed 
of three factors : the arterial pulse-wave, the respir- 
atory wave, and the vascular wave. The respiratory 
wave results from the aspiration of venous blood from 
the brain during inspiration, and the obstruction to its 
flow in expiration. The vascular wave advances like 
a peristaltic movement, and consists in rhythmic dila- 
tations and contractions of the arterioles, apart from 
the cardiac pulse, and dependent on intermittent vaso- 
motor influences. This vascular wave is said by 
Burckhardt' to be much more regular during sleep 
than in the waking period, and constitutes, according 
to this observer, the principal motor mechanism for 
removing waste products through the lymphatic prod- 
ucts. It is said to give two to six tracings a minute. 
Its lowest point (I am now quoting from Meynert's 
citations) corresponds to the contraction, its elevation 
to the relaxation of the arteries. When the wave be- 
gins as systole in the arteries at the base of the brain, 
this is constricted, and the brain mass at the same 
time pushed upward with the advancing column of 

' Ueber Gehirnbewegungen, Mitth. d. Naturf. Gesellsch. in Bern, i88i. 



SOME CONSIDERATIONS ON HYSTERIA. 29 

blood ; simultaneously, the arteries of the convexity 
dilate in diastole and receive the blood ; the cerebral 
hemispheres swell, and, being compressed against the 
rigid skull, compress the roof of the ventricles and 
compel one portion of the ventricular fluid to escape 
by the foramen of Magendie, another portion to flow 
into the veins of the choroid plexus. In the second 
stage the arteries of the convexity are in systole, those 
of the base in diastole, causing swelling of the base, 
which opposes the return into the ventricles of the fluid 
which has escaped into the subarachnoid spaces, so 
that this fluid passes over the convexity of the brain, 
between it and the skull, and enters the great venous 
sinuses. 

If it be true, as is now asserted, that this vascular 
wave is of more importance in the lymph-circulation In 
the brain than either the pulse- or respiratory-wave, 
it Is clear that any disorder of the vaso-motor centres 
which govern it may greatly disturb the removal of 
waste products by interfering with the normal develop- 
ment of such a wave. If, for example, the normal 
intermittence of vaso-motor impulses becomes ex- 
changed for a permanent tonus, the diastolic portion of 
the wave would disappear, and with it the swelling of 
the hemispheres by which the ventricles are com- 
pressed. There would remain the variations in volume 
due to the cardiac systole and diastole ; but in sleep 
these are reduced to a minimum. Hence in any per- 
sons subjected to abnormal vaso-motor irritations must 
exist an imperfect removal of waste products from the 
brain during sleep, and therefore imperfect refresh- 
ment by the great restorer. 

Apart from the foregoing conditions, we may inquire 
whether the diminution of oxygen absorbed during 



30 SOME CONSIDERATIONS ON HYSTERIA. 

sleep — diminution which amounts to twenty-four per 
cent, of that of the waking hours ' — is not Hable in 
hysterics to interfere with the oxidation of waste 
products, and hence with their reduction to the 
most soluble form. The normal diminution cor- 
responds, of course, to the diminished demand 
for oxygen force - compounds, which are evidently 
formed in smaller quantities at night. But the other 
destiny of oxygen in the nervous tissues is the com- 
plete reduction of chemical substances, whose first 
decomposition was attended by the liberation of energy. 
Where the habitual supply of oxygen is very near the 
margin, the diminution during sleep may easily reduce 
it below the amount at which prompt and effective 
oxidations are possible. Hence, by a double mechan- 
ism, the sleep of the neurotic is liable to be uncertain 
and unrefreshing ; to be tormented by bad dreams, 
among which are most characteristic those of falling 
from a height. The restlessness and bad sleep closely 
imitate that of fevers, where the nerve-tissues are sur- 
charged with their own poisonous excreta. 

The curious researches of Anjel ^ on the peripheric 
blood-flow during brain-activity offer experimental in- 
dication of vaso-motor irritation in the brain. In nor- 
mal persons, during mental activity, the turgescence 
of the tissues of a limb enclosed in a plethysmograph 
is found to diminish — presumably from the afflux of 
blood to the brain.^ But in neurasthenics, under the 
same circumstances, the plethysmograph registered no 

' Voit, Hermann's Handbuch, Bd. 6, i., p. 205. 

^Archivfur Psychiat., 1884. 

^ Amidon's experiments on localized rise of temperature in the brain during 
voluntary motor contractions point also to localized cerebral hypersemias. See 
Alumni Prize Essay, College Physicians and Surgeons, 1880, Arch. Med. for 
April. 



SOME CONSIDERATIONS ON HYSTERIA. 3 1 

change. The author infers that from permanent and 
abnormal excess of tonus in the blood-vessels of the 
brain the alterations in its blood-supply are less marked, 
and especially that less abundance of blood is thrown 
into the brain during its functional activity. Hence 
more ready exhaustion by this. 

The motor derangement of hysteria which is opposed 
to paralysis and fatigue is convulsion. The co-ordinate 
character of hysterical convulsion distinctly marks it 
as cerebral, as effected in the highest reflex — i. e.^ the 
co-ordinating — centres, formed by the subcortical 
basal ganglia of the brain. Thus, while sharing the 
cerebral origin of other hysterical phenomena, it does 
not imply a condition of exalted activity of the cortical 
motor centres, which would contradict the general 
theory of their condition we have been trying to 
establish. On the contrary, the excessive excitability 
and activity of the subcortical motor centres imply 
diminished control over these by the cortical centres, 
which normally inhibit them in part. It is well known 
that hysterical convulsions are often brought on by 
painful, or even by simply disagreeable, moral impres- 
sions. 

The following case is all the more worthy of citation, 
because illustrating hysteria in the male subject : 

Case VII. — Man, aged sixty. Long subject to attacks of co- 
ordinated convulsions, diagnosed as hysterical by several Ameri- 
can and European physicians. On one occasion, after a trifling 
altercation at table with an old lady, patient withdrew to his room 
in great offence, and two hours later was seized with severe attack 
of typical convulsion ; the body curved in opisthotomus, then 
bounding from the bed in clonic spasms, these alternating with fits 
of sobbing and tears. Consciousness was evidently preserved 
throughout. 

Painful emotion, it has been said, implies inhibition 



32 SOME CONSIDERATIONS ON HYSTERIA. 

of cortical activities. The inhibited cortical areas lose 
their own power of inhibition over the subcortical sen- 
sory-motor ganglia. If the total cortical area thus in- 
hibited be large, the negative excitation of these ganglia 
may be so great that involuntary but co-ordinate 
muscular contractions ensue (hysterical convulsion). 

The tendency to cortical inhibition should be resisted 
in proportion to the mass of secondary impressions 
which have been previously organized — in virtue of 
the chemical synthesis attending their registration — in 
cortical areas. This theoretical statement agrees per- 
fectly with the observation of common experience, 
that the liability to hysterical convulsion varies in 
inverse proportion to the mass of ideas previously 
organized in the consciousness of the individual. If 
this be small, a slight degree of annoyance suffices for 
the convulsion ; but in the contrary case, the phenom- 
enon, when of mental causation, only appears after 
prolonged and profound disturbance. It is curious to 
notice, however, that hysterical convulsion much more 
often appears after slight than after severe moral 
causes ; the latter seem to arouse impressions that 
re-enforce resistance to inhibition. 

Finally, the convulsion may be spontaneous. Yet, 
of all hysterical accidents, I think this is most fre- 
quently traceable to the immediate influence of moral 
events ; also, is the most often limited to persons of 
narrow intelligence. The post-epileptic hysterical phe- 
nomena noted by Gowers ^ are not infrequently con- 
vulsive. They are considered by this author to mark 
the advent of a slight degree of brain-degeneration ; 
/. e., such impairment of cortical power as diminishes 
cortical inhibition over subcortical ganglionic centres. 

A third form of disorder in the motor sphere is, like 

' Epilepsy. 



SOME CONSIDERATIONS ON HYSTERIA. 33 

paralysis and convulsion, common both to hysteria and 
to organic brain disease — this is contraction or rigidity 
of muscles. In organic disease this follows upon 
paralysis caused by lesion of the pyramidal tract. In 
hysteria the contraction is not necessarily preceded by 
paralysis, and this circumstance is often the only means 
of establishing the diagnosis. In organic disease, mus- 
cular rigidity is known to be associated with sclerosis 
of the lateral columns of the cord, or, more specifically, 
with descending degenerations of the pyramidal tracts. 
Correlatively with this discovery, hysterical contrac- 
tion has also been assigned to these tracts. Charcot 
has even discovered lateral sclerosis in an old woman 
who was said to have suffered for many years before 
death from hysterical contraction. 

The primary condition in descending sclerosis is the 
atrophy of the medullary sheaths of nerve-fibres which 
have been separated from their trophic centres in the 
brain. Trophic centres are evidently those from which 
start nerve-currents. The reason why the fibres of the 
pyramidal tract degenerate after a hemorrhage into 
the internal capsule is, admittedly, because the passage 
of nerve-currents through them is interrupted. The 
same degeneration is observed after lesions of the 
central convolutions, when, though all the mechanisms 
of movement remain intact, the mechanisms for con- 
veying voluntary impulses have been destroyed. 

Is it not possible that, if these mechanisms be, not 
structurally, but functionally impaired, as they are in 
hysteria, and the passage of nerve-currents from vol- 
untary impulses suspended, the nutrition of the centrif- 
ugal tracts may suffer in some manner analogous to 
that by which the medullary sheaths waste in organic 
hemiplegia, but much less intense ? Thence, as a con- 



34 SOME CONSIDERATIONS ON HYSTERIA. 

sequence, the rigidity of the muscles connected with 
these tracts. 

Such a sequence cannot be considered inevitable, 
for there are many cases of hysterical paralysis with- 
out contraction, and many cases of contraction where 
the inability to move the limb begins at the same time 
with its rigidity. But it is difficult to see how the line 
of causation can be in any other direction than that 
indicated. 

Anaesthesia, the first great division of sensory hys- 
terical phenomena, can be interpreted in one of two 
ways. It implies such defective blood-supply to the 
cortical receiving centres that they are unable to 
obtain material for the chemical syntheses of registra- 
tion, though constantly receiving the stimulus of cen- 
tripetal impressions. The anaesthesia would then be 
attributable to vaso-motor spasm. 

But it is probable that the nerve-elements of the sen- 
sory centres may also suffer direct depression of their 
power to respond to stimulus — depression analogous 
to that suffered by the motor centres in paralysis. In 
both cases the depression simply exaggerates the 
habitual defect in the power of force-storage. Anaes- 
thesia, like catalepsy, belongs to the graver forms of 
hysteria. The stimulus to sensory registration is so 
great and so permanent, that in sensory centres the 
defect is habitually overcome, even when obvious in 
others. When these also fail it is evident that the 
defect is unusually great. 

Amblyopia is the most serious form of anaesthesia. 
The following case illustrates the serious difficulty in 
diagnosis which this symptom may occasion : 

Case VIII. — Unmarried woman. Sufferer from various forms 
of neurotic disorder for several years. After a period of several 



SOME CONSIDERATIONS ON HYSTERIA. 35 

months of unusually good health, seized suddenly with the most 
violent pain in eyes, occipital headache, vomiting, and amblyopia, 
which in a day or two increased considerably, but never to total 
blindness. The pupils were widely dilated and insensible to light. 
For two days there was rigidity of the neck and some retraction 
of the head. Pulse and temperature remained normal ; conscious- 
ness was unaffected. No ophthalmoscopic examination at the 
time ; a diagnosis was made of a basilar meningitis localized 
around the optic chiasma. The patient, however, began to recover 
in a week, but remained subject to violent headaches, as indeed 
before the attack. Some years later this patient had an attack of 
incoercible anorexia and vomiting, which terminated fatally in ten 
weeks. At the autopsy the brain, medulla, and cord were care- 
fully and microscopically examined, and not the slightest trace of 
organic lesion found. The vomiting, though fatal, had evidently 
been hysterical, the disturbance in the nerve-centres functional.' 

This termination made it strongly probable that the 
cerebral accidents of the preceding years, including the 
amblyopia, had been also functional, hysterical, devel- 
oped under the same influence — a neuritis of the 
median nerve, — as seemed to be chargeable with the 
final and fatal irritations. 

In minor forms of hysteria, disturbance of the visual 
sphere not leading to amblyopia is extremely common. 
Much of this is due to spasm of accommodation, with 
spasm of the internal recti muscles, or else to paresis 
of the same muscles. These disorders will be presently 
considered. 

Of all hysterical disorders, pain is the most frequent, 
the most distressing, and often the most perplexing, 
either for diagnosis or treatment. The important 
characters of hysterical pains are the following : They 
predominate on the left side of the body ; they are 

* An organic cause for this disturbance existed in the periphery of the ner- 
vous system, in a neuritis of the median nerve. The terminal history of this 
case has just been reported by Dr. R. Osgood Mason, Am. Journ. Med. Scien- 
ces, July, 1886. 



36 SOME CONSIDERATIONS ON HYSTERIA. 

entirely out of proportion to the peripheric Irritation 
in which they seem to originate, both in Intensity and 
duration ; they are capable of surviving the complete 
subsidence of peripheric irritation ; they may exist in 
the absence of all ascertainable peripheric irritation ; 
they often develop and cease, like other hysterical 
symptoms, under the influence of moral impressions ; 
they are constantly liable to diffuse from the locality 
In which they first appeared into others, not adjacent, 
but often connected with the first by ramifications of 
the same nerve-plexus. The diffusion, however, easily 
exceeds these limits, and often is general. At other 
times, however, pain may remain with the utmost 
tenacity, limited to a single spot or nerve-trunk for 
years. ^ 

Spots of hyperaesthesia are usually aggravated by 
pressure ; deeper-seated pain is sometimes relieved by 
it ; thus especially in the head, and when seated in the 
muscles of the back. 

The reactions of hysterical pain to electricity are also 
variable, although, as a rule, galvanism has a surpris- 
ing effect in dissipating these pains, — at least for a 
time. 

Case IX. — Complains of fixed pain in track of last dorsal and 
ilio-hypogastric nerve, and in iliac branch of the latter. This local- 
ity is a frequent seat of hysterical pain, with or without distinct 
ovarian hyperaesthesia, with which the ilio-hypogastric pain is fre- 
quently associated. The application of a galvanic current of fif- 
teen milli-amperes, descending from the spinal cord along the 
nerves, invariably relieved the pain in ten minutes. After half a 
dozen applications the patient professed herself entirely cured, for 
the time at least, though the pain had previously persisted with 
more or less intensity for a year. 

^ Charcot has recently pointed out the error of considering hysterical phe- 
nomena to be necessarily fugacious and mobile. 



SOME CONSIDERATIONS ON HYSTERIA. 37 

Case X. — Married woman, thirty-five years of age. Marked 
hysterical temperament, in the form of emotional excitability. 
Symptoms developed after a winter passed in nursing a relative, and 
suffering with much physical fatigue, and also anxiety. There 
was uterine catarrh of moderate severity ; hypersesthesia, without 
hypersemia of fundal endometrium ; left ovarian hyperaesthesia 
marked ; ovary not perceptible. No dysmenorrhoea, but subject 
to violent " bursting " headaches just before menstruation, im- 
mediately relieved by flow. During premenstrual week, invariably 
severe mental depression. 

In addition to the headaches and the fixed pain in the ovarian 
region, the patient suffered from pain in the cutaneous branch of 
the second lumbar nerve w^here it passes over the left hip, in the 
middle gluteal nerve on the same side, and in the left pudic nerve. 
All these pains, as well as ordinary headache, could invariably be 
dissipated for several hours, or even days, by galvanism applied 
with the polar method. There seemed to be no difference be- 
tween the effect of the two poles. The method was not tried on 
the premenstrual headache 

This patient was subjected to a certain amount of 
intra-uterine treatment, which was always very per- 
turbating. The patient certainly derived no immedi- 
ate benefit from this, though immediately after its 
cessation, and on going into the country, she became 
quite well. The galvanism, however, retained a per- 
manently beneficial influence, whose duration con- 
stantly increased. My present impression is that this 
treatment would have sufficed, with time, to cure her ; 
but while under my treatment she at one time con- 
sulted a prominent gynecologist, who diagnosed 
endometritis and ovaritis, and advised a six weeks' 
residence in his hospital. This advice was not fol- 
lowed, but it was about six weeks later that all symp- 
toms disappeared. 

Case XI. — In this case, a girl of naturally hysterical tempera- 
ment, developed the most marked hysterical symptoms in connec- 



38 SOME CONSIDERATONS ON HYSTERIA. 

tion with a retroversio uteri, some of which persisted, though 
much relieved, after the position of the uterus had been rectified. 
Among these appeared a new symptom — pain in a fixed part of 
the vagina, apparently in a branch of the pudic nerve. This pain 
caused, for a long time, endless trouble about the pessary, which, 
however, had evidently nothing to do with it ; and was so much 
aggravated by walking that the patient scarcely took any exer- 
cise. The pain was aggravated by galvanism, but yielded to a 
few applications of iodine, made while the patient was being much 
benefited from the health-lift. 

Case XII. — A robust young German woman, twenty-eight 
years of age, consulted for violent pains, which occupied nearly 
all the branches of the left lumbar plexus, accompanied by 
ovarian hypersesthesia, and which had lasted a year. These pains 
would be subdued during the application of a strong galvanic 
current, but would return in from five to ten minutes afterward. 
There was no ascertainable utero-ovarian disease. Hysterical 
symptoms during the year the patient was under observation, but 
no history of these could be obtained at first. At the end of a 
year the patient was in the same condition, and disappeared from 
observation. 

Case XIII. — Young lady, thirty-two years of age. Lithaemic 
family history ; some relatives with marked hysterical hypochon- 
driasis. Patient herself had had several attacks of hysterical 
affections of different kinds, and now consulted for a spot of 
pain in left ovarian region of abdomen, that, at first thought, 
might have been associated with uterine or ovarian lesion, but 
which soon showed itself as pure ovarian hypersesthesia. This 
pain was relieved by galvanism, but more so and more perma- 
nently by faradism, applied externally, and disappeared after- a 
few applications, though it had previously lasted six months. 

Case XIV. — Young woman, about thirty years of age. Marked 
and peculiar hysterical egotism ; complained of a pain in track of 
right twelfth intercostal nerve, said to have lasted seven years. 
Said to have been aggravated by exercise taken under advice of 
physician. This pain was quite unaffected by electricity. 

Case XV. — Unmarried girl, twenty-seven years of age. Pain 
in left crural nerve of eighteen months' duration, during a year of 
which patient had not walked at all. Either galvanism or faradism 
temporarily relieved pain, but did not cure it. Patient subse- 
quently cured by sojourn at Weir Mitchell's hospital, where fara- 



SOME CONSIDERATIONS ON HYSTERIA. 39 

dism was applied to every part of the body except the affected 
nerve. 

Case XVI. — Very delicate girl of nineteen years of age. Two 
years previously severe chloro-ansemia, with amenorrhoea of six 
months' duration. Recovery. Then severe moral strain through 
illness and death of father. Patient profoundly prostrated in 
strength, though making every exertion; constant fatigue, anorexia, 
much insomnia, nervous fever, headache constant, with frequent 
exacerbations. Tonics, given at first by another physician, pro- 
duced no effect. Headache finally greatly improved by mild gal- 
vanic current, nape to forehead, and with labile passes here. 
Relief persisted for twenty-four hours, and was especially marked 
to the distress which had existed at the nape of the neck. 

Case XVII. — Markedly hysterical constitution, though of an 
active and cultivated intelligence and most affectionate disposi- 
tion. Ovarian hyperiesthesia developed, together with a retrover- 
sion of the uterus, immediately upon an arrest to menstruation 
through a moral shock received while menstruating. Amenorrhoea 
persisted for a year ; then menstruation returned, but was often 
accompanied by hemorrhage from the rectum. The ovarian 
hyperaesthesia persisted for three years more, causing almost 
entire inability to walk. During this period, however, it was 
always relieved, and seemed gradually to abate and disappear, 
under the daily application, externally, of faradic electricity. 

Case XVIII. — Unmarried woman, thirty-eight years of age. 
Many hysterical symptoms. Pain in right knee, developed after 
slight sprain, and persisting for several weeks. Readily dissipated 
by a very mild application of galvanism ; polar method, anode 
to knee. Some return of pain cured in same way, as rapid and 
more permanent cure effected by strychnine. 

The following case illustrates the development of 
pains by moral impressions, in a way that is all the 
more interesting from the age and sincerity of the 
patient. 

Case XIX. — Woman, fifty-six years of age. Neurotic symp- 
toms of many kinds for many years. A month after death of hus- 
band, to whom she was much attached, and whom she had nursed 
through a trying illness, patient began to have the most agonizing 
pains darting all over the body. The pains had lasted a fortnight 



40 SOME CONSIDERATIONS ON HYSTERIA. 

when I saw the patient. They rapidly yielded to bromide and 
valerian, though for some weeks showing a constant tendency to 
return. 

The same line of reasoning which, as I think, estab- 
lishes the cerebral nature of hysterical paralysis, anaes- 
thesia, and contraction,' should assign the far more 
frequent phenomenon of hysterical pain also to the 
cerebral sensory centres. ''The impressions of the 
[entire] body are conveyed to the brain by the rami- 
fications of all the nerves and their terminal organs ; 
mutato Tfiutandis we may argue that the cerebral cor- 
tex is the surface upon which the entire body is pro- 
jected by means of these nerves."^ No sensory im- 
pression can rise into consciousness until it has been 
thus projected upon the cortex ; conversely, the sen- 
sory impressions that exist in consciousness, without 
any objective justification, can only arise in the cor- 
tex. The sensory hallucinations of insanity suffi- 
ciently prove that the cortical terminations of sensory 
nerves, in this case most notably those of special 
sense, are capable of generating impressions which 
are referred to the periphery. The pains of pure 
hysteria can only be hallucinations analogous to those 
of insanity, and generated in the sensory centres of 
the cortex. For where else could they be generated ? 

As in insanity slight lesions of the auditory appa- 
ratus may initiate hallucinations of hearing which 
suffice for a basis to a delirium of persecution ; so in 
hysteria slight, and even physiological, impressions 
may suffice to initiate hallucinations of pain in morbid 
sensory centres. The brain-cortex is the only part of 

^ The cerebral nature of hysterical convulsion is not, I think, called in ques- 
tion. ^ Meynert, loc. cit., p. 39. 



SOME CONSIDERATIONS ON HYSTERIA. 4 1 

the nervous system which possesses the power of im- 
measurably magnifying an impression, in a way that 
we can perhaps rudely represent by the action of the 
galvanometer or the boussole. This magnifying power, 
and still more the capacity for generating a hallucina- 
tion of pain in the absence of all irritation, is often 
clinically interpreted as the ''imagination" and ''ex- 
aggeration " of hysterics. These expressions, which, 
properly understood, really place the pain on the most 
profound morbid basis, by referring it to disordered 
action of the brain, are, singularly enough, often taken 
to justify a contemptuous dismissal of the whole sub- 
ject. But what can be more serious than a fact of con- 
sciousness which has been produced by illicit means ? 

The remarkable diffusion of hysterical pains is often 
interpreted as indicating diminution of resistance in 
the spinal cord, with consequent irradiation in it of 
centripetal impressions. But irradiation in the cord 
does not lead to diffusion of sensation, but to wider 
response in reflex movement. This is shown in 
Pfliiger's experiment, and probably also in strychnine- 
poisoning. 

On the other hand, a moderate degree of diffusion 
of impression through the receiving-centres of the 
brain would cause the excitation of areas belonging to 
centripetal nerves which terminate on the periphery 
at some distance from the one originally irritated. 
The course of centripetal nerve-fibres may be com- 
pared to a sheaf, expanding at both ends and com- 
pressed in the middle. The separation of the central 
terminations of nerve-fibres at the cortex corresponds 
to the much wider separation of the same fibres at the 
periphery. 

By a diffusion of the irritation from a single focus 



42 SOME CONSIDERATIONS ON HYSTERIA. 

may be excited any or all of the pains so characteristic 
of hysteria — the clavus, inframammary, third inter- 
costal, praecordial, epigastric, infrascapular pains ; 
those in the track of the external branches of the 
lumbar and sacral plexus, the pain over the crest of 
the ilium, and, possibly, the ovarian hypersesthesia. 

The frequency with which pain is referred to the 
regions of the lumbar and sacral plexus, even in the 
absence of any utero-ovarian disease, may be ex- 
plained, at least in part, by the masses of impressions 
which are being continually generated at the periph- 
eric expansion of the utero-ovarian nerve during 
the rhythmic processes of menstruation. The fre- 
quency of slight disorders of these processes increases 
the probability of morbidly affecting the cerebral sen- 
sory centres through their medium. But, as will 
presently be shown, vaso-motor spasm probably plays 
an important role in the sensory symptoms referred to 
the pelvis, notably in the ovarian hyperaesthesia. 

Pain in the track of the occipital and trigeminal 
nerves, the basis of some of the most violent head- 
aches observed in neurotics, is often difficult to inter- 
pret. Are these true neuralagias, irritations of the 
roots of nerves by obscure nutritive changes in their 
nuclei of origin ? It is well known that Anstie ex- 
plains neuralgic pain by atrophy of the posterior 
nerve-roots — minor degree of the lesion which causes 
the pains of tabes dorsalis. 

The old and oft-quoted remark of Romberg, that 
"pain is the cry of the nerve for healthy blood," has 
led almost to a habit of referring these and other 
neuralgias to anaemia. They are certainly often as- 
sociated with lithsemia. Apart from general condi- 
tions interfering with the abundance or the purity of 



SOME CONSIDERATIONS ON HYSTERIA. 43 

the blood-supply, the medullary and upper cervical 
nerves are especially exposed to localized anaemias 
during Irritations of the medullary vaso-motor centre. 
Such Irritations are most frequent In hysteria. 

But all the foregoing causes produce pain directly ; 
a real change takes place In the sensory roots, or the 
nuclei of origin of the nerves, which Is simply regis- 
tered by their cortical fibres in the sensory regions of 
the cortex. When due to vaso-motor spasms, these 
neuralgias may be Indirectly due to hysteria. In other 
cases they may be simply associated with hysteria. 
Finally, though there be at present no absolute proof of 
such an occurrence, there seems no reason why sensory 
irritations should not diffuse into the cortical areas of 
the trigeminal and occipital as into those of other 
nerves, and thus pain be referred to their distribution 
even when both their peripheric expansion and nuclei 
of origin were intact. 

Pain in the head — headache — can never be the 
direct expression of irritations of the cerebral sensory 
centres, for such irritations are always referred to the 
periphery of the nerves connected with these centres. 
The location of pain in the head after cerebral 
irritation implies that irritation has been referred to 
the ramifications of the trigeminal nerve in the dura 
mater, or to the branches of the occipital nerve dis- 
tributed over the scalp. 

This pain may originate in several ways. In the 
first place, typical hallucinations of pain may be gen- 
erated In the cortical centres for the dura mater 
nerves, and referred to their periphery, as in hysterical 
pelvic pains.' In the second place, hysterical vaso- 

'See Fox (Diseases, Sympathetic, chap, on Hysteria) for analysis of the ac- 
tion of the otic ganglion upon the sensitive nerves of dura mater. 



44 SOME CONSIDERATIONS ON HYSTERIA. 

motor irritations, generated through lack of cortical 
control over vaso-motor centres, may cause spasmodic 
anaemia of the nuclei or spinal roots of these nerves, 
or diffused neuro-paralytic congestions of the dura 
mater. Finally, true neuralgias of these nerves from 
general anaemia, or from lithaemia, may develop in 
hysterical persons, and associate themselves with 
typically hysterical symptoms. 

Case XX. — Amenorrhoea and severe headache, almost inces- 
sant for two or three years. Frequently paroxysms of neuralgi- 
form pain in nape of neck, and extending forward in track of 
superficial cervical plexus. These paroxysms always relieved and 
finally cured by aconitia, which had no effect on the headache at 
all. 

Hemicrania has long been regarded as a vaso-motor 
neurosis ; as such it is sometimes hysterical, some- 
times direct, especially from the blood-poisoning of 
lithaemic indigestion. A number of distressing paraes- 
thesias in the head are most common in hysteria and 
in uterine disease — the head is too big; is empty, 
hollow ; is burning, etc. Vertical and occipital head- 
ache is most characteristic of uterine disease, and of 
uterine hysteria. A constant, diffused, dull headache 
is also frequent, and would be best explained by 
diffused congestion of the dura mater through vaso- 
motor paresis. 

The following case illustrates the mode of develop- 
ment of these cerebral paraesthesias, in a way all the 
more interesting because it is analogous to, and not 
identical with cases previously quoted. 

Case XXI. — Boy, aged twelve ; mother anaemic and hysteri- 
cal, father healthy. Said to have suffered during five years from 
headache ; become most intolerable during last two years, worse 
in the morning. Head seems to patient to be very large, hollow, 



SOME CONSIDERATIONS ON HYSTERIA. 45 

affected with constant, diffused, dull pain ; this frequently exas- 
perated into violent paroxysms. During last year has great dis- 
inclination to walk ; feels as if he would fall, becomes exhausted, 
often with increased pain in head ; will stand and hold on to a rail- 
ing. Was seen by several eminent physicians, being under the 
care of one excellent neurologist for two years with little benefit- 
Finally the mother consulted a surgeon, who discovered a phimo- 
sis and operated. The boy suffered from violent nervous agita- 
tion and headache for ten days, then recovered. The inability to 
walk was entirely relieved ; the headaches markedly so, with pro- 
gressive improvement. 

In predisposed persons depressing moral emotions, 
may suffice to induce headache of several years' dura- 
tion. 

Case XXII. and Case XXIII. were both extremely anaemic 
young women. In each, after severe moral strain associated with 
disappointment in marriage, almost constant headache ; most se- 
vere at the occiput, frequently exaggerated into the most violent 
paroxysms. In one case these headaches lasted seven years ; in 
the other, four or five ; yielding to no remedy, but finally to time. 

The generation of hallucinations of pain in cortical 
centres, like the hallucinations of visional and auditory 
centres in insanity, in the entire absence of alteration 
at the periphery or root of nerves, would imply that 
the ordinary impressions which passed upward from 
peripheric nerve-terminations were registered in excess, 
on account of the hyperexcitability of the registering 
apparatus. In a photographic apparatus, rays of 
light of the same intensity produce chemical decom- 
positions which vary in amount (depth) according to 
the chemical preparation of the receiving plate, i. e., 
according to its sensitiveness. This may represent 
one analogy. The hallucinations of insanity furnish, 
by another analogy, indications of the truth of the 
proposition maintained earlier in this paper, namely, 



46 SOME CONSIDERATIONS ON HYSTERIA. 

that excitability of the sensory centres is increased in 
proportion as the functional activity of other portions 
of the brain is depressed or inhibited. 

Visual hallucinations are by no means uncommon 
in hysteria. Dr. Hammond has referred visual hallu- 
cinations to disease of the thalamus, and thinks that 
they are precursors of a special form of epilepsy, called 
by the author ** thalamic." The numerous connections 
of the thalamus with the optic tract ' render extremely 
plausible the suggestion that a morbid process in this 
ganglionic mass may generate impressions which shall 
be referred by the optic tract to the retina. Of such 
impressions, however, the cortical visual centres must, 
since they rise into consciousness, be the spectator 
and registrar. Further, the hallucination is composed 
of elements drawn from memory, i. e.^ from secondary 
impressions previously registered in the cortex. It is 
certain, therefore, that the cortex is involved in the 
disorder, even if its original starting-point be in the 
thalamus. It seems more probable that the morbid 
impression is thus first carried by fibres of the optic 
tract to the cortical visual centre in the cuneus,^ thence 
** referred " by the usual mechanism of illusion ^ to the 
retina and outside world. Apart from the coexist- 
ence of sequence of epileptic convulsions — or else of 
proof of organic disease of the thalamus — there is, 
however, no proof that visual hallucinations originate 
in it rather than in the visual centres themselves. 

The two following cases illustrate the effect of a 
prolonged excess of sensory impressions conveyed 
through upper nerve-tracts to the brain-centres : 

* Through the posterior fasciculus, the pulvinar, and the corpus geniculatus 
externus. 

" Exner, loc. cit. Seguin, Journal of Nervous Diseases, January, 1886. 

* Whatever that may be. 



SOME CONSIDERATIONS ON HYSTERIA. 47 

Case XXIV. — Aged thirty-four. From fifteen to twenty-eight 
engaged in excessive playing on the piano as accompanist to sing- 
ing-teacher, sometimes ten to twelve hours a day. Six years ago 
begun to suffer with nervous diarrhoea, and this lasted a year ; 
still liable to attacks of it. Five years^ago began to have distress 
in nape of neck, and after a month, while playing on the piano, 
arms suddenly ^' gave out." The patient was ''prostrated" in 
bed for two months, and has never since been able to touch the 
piano. Even the placing of the fingers on the keys — or on a 
table in the attitude of playing — causes sensation of nausea, and 
of distress at nape of neck. The same is caused by touching fin- 
ger-tips, which are excessively sensitive. There is no pain in track 
of the nerves ; the morbid response to touch is felt immediately 
near the roots of the cervico-brachial plexus. There are often 
sensations of numbness in the right arm, and occasional pains. 
The act of turning the head or lifting the eyes causes nausea, and 
even "great anguish." When the nape of the neck is supported, 
the patient feels "perfectly comfortable." The head is the seat 
of many distressing sensations, though rarely of distinct pain. It 
sometimes seems enormously big, sometimes perfectly empty (sen- 
sations analogous to effect of cannabis indica). Inability for men- 
tal exertion marked. 

On one occasion patient had been to the Catskills, 
and had Immediately begun to suffer from '' frightful 
dizziness," and was obliged to leave. On another 
occasion, at the Clinton Water Cure, had attack of 
Incomplete paraplegia. This was cured by the Swedish 
movement treatment. During the five years that the 
patient had been more or less subject to these symp- 
toms there had been many Intervals of comparative 
health, but never of complete recovery. 

This case approximated to the great class of func- 
tional neuroses which usually express themselves in 
localized convulsions on the attempt to execute cer- 
tain co-ordinated movements. There were no con- 
vulsions, however, and very little pain ; apparently no 
psychic symptoms, except the inability for mental 



48 SOME CONSIDERATIONS ON HYSTERIA. 

exertion. The attack of paraplegia was characteristic- 
ally hysterical. 

The etiology of this morbid state in an excess of 
function demanding complex muscular co-ordination, 
together with the predominance of symptoms of 
nausea and vertigo, and the degree of relief afforded 
when the back of the head was supported, all point to 
functional exhaustion — exhaustion of power to store 
force — of the co-ordinating mechanisms of the cere- 
bellum, probably associated with a similar condition 
of the thalamus through the medium of the recurving 
fibres passing between thalamus and cerebellum, 
through the tegmentum and pons. The cortex of the 
cerebrum was only occasionally, and secondarily, in- 
volved ; and, correlatively, hysterical symptoms proper 
were few and transitory ; there was but a slight degree 
of mental inhibition ; no noticeable psychic pain, but, 
however, an attack of paraplegia. The case is quoted 
here, not as an example of hysteria, but of a morbid 
state lying on the border-line of hysteria, but distinct 
from It. 

Case XXV. — This case has already been mentioned while 
speaking of hysterical amblyopia. It has just been related in full 
by Dr. Osgood Mason. ^ A large train of neurotic symptoms, 
which, after fifteen years, finally culminated in incoercible vomit- 
ing and death by inanition, were caused by a neuritis of the 
median and musculo-spiral nerve. The neuritis was due to a 
splinter run into the palm of the hand at the age of two and a half 
years, and not removed until the age of twenty-two, when the first 
symptoms of neuritis developed after a blow on the hand in which 
the splinter was imbedded. The patient was operated upon 
several times,^ by section of the median nerve for the intense pain 
in the arm, and recovered from this ; so, indeed, that between 

^ Am. J. Med. Sciences, July, 1886. 

^ Once by Dr. Sapolini, of Naples ; three times by Dr. Weir Mitchell, of 
Philadelphia, or rather in consultation with him and by his advice. 



SOME CONSIDERATIONS ON HYSTERIA. 49 

1878 and 1885, the date of her death, she had no local suffering. 
But, as the autopsy showed, the neuritis continued to progress in 
the central segment of the divided nerve ; the patient suffered 
from several severe attacks of pain in the neck in the course of 
the cervical plexus, but much more frequently from violent head- 
aches and a series of disturbances which, as quoted from me in 
Dr. Mason's paper, I have thus classified : 

First period. — Mental depression, with religious excitement, 
followed by severe facial acne. Duration, four months. 

Second period, — Utero-ovarian congestion, followed by retrover- 
sion, ovarian prolapse ; then recovery after eighteen months. 

Third period. — After three months' good health, attack of 
pseudo-meningitis, with violent headache, vomiting, profound pros- 
tration, retraction head, rigidity cervical muscles, intense vertigo, 
amblyopia, dilatation and insensibility of pupils, absence fever. 
Duration, eight weeks. 

Fourth period. — Headache, with localized tenderness of scalp, 
some local rise of temperature at same spot, sensations of burst- 
ing in head, nausea, stumbling gait, heaviness in limbs. Relieved 
by cauterization of head ; then by iodide sodium. 

Fifth period. — Severe nervous dyspepsia ; relieved by faradi- 
zation. 

Sixth period. — Mental depression approaching to melancholia. 

Seventh period. — Increase of dyspepsia, alternating with head- 
ache, vertigo, and prostration, and once transitory diabetes ; fi- 
nally, the attack of violent dyspepsia in which the patient lost her 
life. 

The autopsy was completely negative of result, except as re- 
gards the nerves in the brachial plexus. Signs of neuritis were 
found high up in the plexus, in the musculo-spiral and median 
nerve ; but nothing in cord, medulla, or brain. The violent, long- 
continued, and finally fatal disturbance of the central nervous 
system was therefore purely functional. 

The phenomena of the disturbance were fourfold : 
I. Mental (frequent attacks of mental depression bor- 
dering on melancholia, and which the patient dis- 
tinguished readily from the '' normal " effects of her 
prolonged sufferings). 

2. Vaso-motor (expressed by the transient utero- 



50 SOME CONSIDERATIONS ON HYSTERIA. 

ovarian congestion, the purple redness of face attend- 
ing the pachymeningitic form of headache, possibly 
also by the severe acne). 

3. Sensory (violent headaches, attacks of numbness 
in limb, attack of amblyopia). 

4. Visceral (gastric attacks, which, once begun, in- 
creased in frequency, duration, and intensity until the 
fatal issue). 

Dr. Mason quotes me as ascribing all these phe- 
nomena to a series of vaso-motor neuroses. I should 
to-day look for the fundamental conditions in the 
brain-cortex, so long the recipient of masses of irri- 
tating impressions coming from the diseased nerves. 

When, after division of the nerves, these impres- 
sions could no longer be referred to their peripheric 
termination, they diffused into the cortical areas of 
the trigeminal and occipital nerves, causing the violent 
headaches referred to their termination in the dura 
and scalp. As a consequence of this excitation of the 
sensory centres, followed various degrees of cerebral 
inhibition. When this inhibition was generalized, the 
patient suffered from psychic pain. When the inhibi- 
tion especially affected the visual centre, the patient 
had the attack of amblyopia coinciding with the most 
intense mental and motor prostration. 

When the cortex was inhibited in the rest of its 
functional activities, its inhibiting control over the 
subcortical vaso-motor centres was proportionally 
weakened, a condition which left these centres to an 
exaggerated activity. 

Stimulation of the vaso-motor centre is a known 
physiological result of sudden irritations of sensory 
nerves, and may be inferred to have existed during at 
least the exacerbations of the neuritis. The symp- 



SOME CONSIDERATIONS ON HYSTERIA. 5 1 

tomatology of the case contained nothing positively 
indicative of exaggerated vaso-motor tonus. There 
were, however, many symptoms only explicable by 
vaso-motor paresis, which rarely comes on except as a 
consequence of previous excess of tonus. 

The final illness, comprised of visceral symptoms, 
was evidently a neurosis of the pneumogastric. Pre- 
ceded as it was by the attack of diabetes, it indicated 
an affection of the medulla, which we may most plau- 
sibly, however obscurely, associate with the long- 
standing sensory irritation of the medullary vaso-motor 
centre. 

The theory of Meynert, in regard to vaso-motor 
excitation from withdrawal of the control normally 
exercised by the cortex of the brain, explains 
hysterical vaso-motor neuroses as none other can. By 
it these neuroses are linked with the same funda- 
mental conditions as underlie the sensory, motor, and 
psychic phenomena of hysteria. 

Upon this theory (which has been already exposed), 
and in view of the many facts which justify the locali- 
zation of hysteria in the brain, the vaso-motor neuroses 
of the disease might probably be called negative, be- 
cause due to the withdrawal of the control over vaso- 
motor centres which should normally be exercised by 
the cortex. Positive vaso-motor neuroses, on the 
other hand, are those which are caused by excitation 
of vaso-motor centres through irritation of sensory 
nerves. These may be present in hysterical people, 
but are not the typically hysterical phenomena as are 
the others. 

The irritability of the vaso-motor system in hysterics 
is indicated by an immense number of symptoms, 
among which " cold chills " and cold hands and feet, 



52 SOME CONSIDERATIONS ON HYSTERIA. 

perhaps alternating with flushing and sweating/ are 
very frequent. 

There are three other and more debatable phenom- 
ena observable in hysterics — the first occasionally, 
the other two very frequently — that I think may be 
also referred to the vaso-motor neuroses. The first of 
these is transient albuminuria. 

Studies upon the albuminuria of fever, initiated by 
Cohnheim and ingeniously pursued by Mendelsohn,^ 
have indicated that the initial event in this morbid 
process is irritation of the vaso-motor nerves of the 
renal plexus. In fever, the kidney, as measured by 
Ray's oncometer, was found to shrink in bulk coin- 
cidently with the appearance of the albuminuria. The 
shrinkage implied diminished blood -supply, which 
could only be attributed to contraction of the arterioles 
under the influence of vaso-motor irritation. With 
this fall of the arterial current and diminished supply 
of arterial blood, there would be a fall of arterial ten- 
sion, consequently rise of venous tension, venous 
hyperaemia, venous malnutrition of the epithelium of 
the glomeruli, hence albuminuria, as a result of its 
anoxaemia and perverted action. 

If such a train of sequences can be determined by 
the vaso-motor irritations of fever, it can be so also by 
others, including those of hysteria.^ 

Case XXVI. — Delicate young lady. Subject to sick head- 
aches, associated with gastric catarrh. The latter was being 
treated successfully by washing of the stomach, when a severe 
hysterical attack occurred, with much purely symptomatic emo- 

^ To which Beard has given a special sexual significance. 

'^ Prize Essay, Alumni College of Physicians and Surgeons, American Jour- 
nal of the Medical Sciences, vol. xviii. 

^ Or of lithsemia, as suggested by Dr. Kinnicutt, Archives of Medicine, 
February, 1882.. 



SOME CONSIDERATIONS ON HYSTERIA. 53 

tional disturbance. Urine examined during this attack exhibited 
a trace of albumen ; the tension of the radial pulse was high. 
Pilocarpine was given, and in twenty-four hours the albumen had 
disappeared, not to return. It had never been noticed before. 

Case XXVII. — Extremely fragile and anaemic girl, with some 
endometritis and numerous neurotic symptoms, that, however, 
did not prevent her from engaging in steady work at a govern- 
ment clerkship. On several occasions albumen appeared in the 
urine, without a trace of microscopical alteration of the latter. A 
physician diagnosed nephritis and prescribed a vegetable diet, upon 
which patient did not improve. On one occasion, while on this 
diet, I found considerable albumen, but nevertheless prescribed a 
meat diet. Two days later all trace of albumen had disappeared. 

These discoveries in regard to vaso-motor irritation 
of the kidney suggest, by analogy, a vaso-motor ex- 
planation for the celebrated phenomenon, ovarian 
hyperaesthesia. It is certainly not at all impossible 
that the seat of this phenomenon, as of the extraordi- 
nary pelvic parsesthesias which may coincide with it, is 
in the cortex of the brain, at the final terminus of the 
centripetal fibres carried in the utero-ovarian nerve. 
But all of the fibres of the ovarian nerve whose termi- 
nation has, so far, been traced, pass to blood-vessels. 
These fibres must have vaso-motor functions, hence be 
centrifugal in direction, although there are, doubtless, 
others centripetal and endowed with functions of com- 
mon sensibility. The facility of vaso-motor irritation 
in the ovary is obvious. May we assume, at least pro- 
visionally, that the vaso-motor nerves of the ovary are 
habitually controlled by those cortical areas in which 
the centripetal fibres of the utero-ovarian nerve termi- 
nate ? Loss of inhibiting power in these areas would 
be felt as vaso-motor excitation at the point of periph- 
eric origin of that nerve ; that is, as spasm of the 
arterioles of the ovary. The result of such spasm is 



54 SOME CONSIDERATIONS ON HYSTERIA. 

a diminution in the amount of normal blood sent to 
the ovary. 

Diminution of the arterial blood-supply causes dysp- 
noea of nerve-elements so exquisitely dependent upon 
oxygen ; this, with or without consequent venous 
hyperaemia, must become a source of irritation to the 
ovarian nerve. This ovarian irri^tation has been ren- 
dered classical by Charcot, as a characteristic " stigma " 
of hysteria. It undoubtedly often exists in the ab- 
sence of all appreciable lesion of the pelvic organs. 
But the pain and the diffused parsesthesias^the feel- 
ings of swellings, burning, etc. — do not differ in form 
from those which coincide with enlargement and pro- 
lapse of the ovary, with endometritis or displacement 
of the uterus. Such lesions^ indeed, can only be ex- 
cluded after a scrupulous local examination. As this 
was omitted in all of Richer's cases,' it is quite impos- 
sible to tell from the histories how far the symptoms 
in these cases were purely hysterical, and how far 
the hysteria was symptomatic of utero-ovarian disease. 

The third symptom to be considered in this connec- 
tion is amenorrhcea. The discovery of the vascular 
wave in arteries, which has suggested so many fruitful 
considerations in regard to the arteries of the brain, 
may be applied to those of the uterus also. It is such 
a peristaltic wave that should propel blood through 
the uterus toward the endometrium during the men- 
strual hemorrhage. Vaso-motor irritation interfering 
with the regularity of this wave may determine cramps 
of the uterine muscle — hence dysmenorrhcea in the 
absence of uterine lesion, — and is probably the zm- 
mediate cause of such pain even when organic lesion 
exists, and is the ultimate cause of the vaso-motor 

^ Recherches sur I'Hystero-epilepsie, 1884. 



SOME CONSIDERATIONS ON HYSTERIA. 55 

irritation. In the highest degree of such irritation 
spasmodic closure of the arteries would arrest the flow 
and cause amenorrhcea. With an exaggeration of the 
peristaltic wave, which may be compared to the ex- 
aggerated peristalsis of the intestine which causes 
certain forms of nervous diarrhoea, there should be 
menorrhagia. Tait's ovarian menorrhagia is probably 
of this description, and the multiplication of follicles on 
the surface of the ovary observed after it has existed 
for some time would be the consequence, and not the 
cause, of the hypersemia. These two opposite condi- 
tions — amenorrhcea and menorrhagia — are mentioned 
here because both are so extremely common in all 
grades of hysteria, and because both, by the theory of 
the vascular wave, are traceable to derangements in the 
vaso-motor apparatus of the utero-ovarian system. 
Either the entire series of vaso-motor centres, or, more 
especially, that located in the lumbar cord is at fault. 
The over-excitability of such vaso-motor centres, 
which, on this theory, should exist in many cases of 
amenorrhcea, would be explained by Meynert's theory 
of loss of control over them when the activity of the 
brain-cortex was enfeebled. Thus would be explained 
the frequency of amenorrhcea in hysteria and in melan- 
cholia, where it is, indeed, the rule, and is associated 
with many other signs of vaso-motor disturbance. 
Kraft Ebing enumerates tendency to amenorrhcea 
among the signs of the neurotic constitution which 
constitutes the predisposition to insanity.' 

Case XXVIII. — Girl, nineteen years of age. Subject to 
periods of amenorrhcea, lasting six months at a time. As soon as 
the amenorrhcea began patient fell into a state of mild melancho- 
liaj which lasted until menstruation returned. During three years 

^ " Psychiatric," Bd. i. 



56 SOME CONSIDERATIONS ON HYSTERIA. 

the menstruation, once arrested, did not return, except under the 
influence of a sea voyage, which after a while was regularly re- 
sorted to whenever the menstruation ceased. 

The melancholia was attributed by a distinguished 
gynecologist to the amenorrhoea. It is much more 
probable that the amenorrhoea resulted from negative 
vaso-motor excitation, due to loss of cortical control 
through hysterical cortical inhibition, the latter being 
the immediate cause of the psychic symptoms. 

Case XXIX. — Girl, aged twenty-two, who until twenty only 
menstruated once or twice a year, and had been the subject of 
several hysterical disorders. The last was an hysterical arthralgia, 
which confined her to her room for an entire year. During this 
time, however, the patient was, apart from the arthralgia, perfectly 
well, free from headaches, and menstruated regularly. A few 
months after recovery from the arthralgia she received news while 
menstruating which caused a severe shock and moral distress. 
The flow was at once arrested, and the patient began to suffer 
from rather severe pain in the left ovarian region. Two or three 
weeks later the uterus was found retroverted, the left ovary acces- 
sible and tender. The physician consulted replaced the uterus 
and applied ice over the ovarian region, with a view of lessening 
ovarian congestion and thus restoring the menstrual flow. The 
theory of the treatment was erroneous, and the treatment cer- 
tainly unsuccessful, for the amenorrhoea persisted for a year, 
accompanied by almost entire inability to walk. Menstruation 
finally returned after a visit to Franzenbad. The ovarian hyper- 
esthesia and pain on walking persisted for three years longer, 
then the patient entirely recovered. 

Recovery in such cases, as well as the previous 
occurrence of regular menstruation, proves that the 
amenorrhoea cannot be due to hypoplasia, or defective 
development of the aorta or pelvic arteries. In an- 
other place ' I have endeavored to set forth a special 
view of menstruation, which claims that the blood lost 
in the menstrual hemorrhage is determined to the 

^ American Journal of Obstetrics, 1885, 1886. 



SOME CONSIDERATIONS ON HYSTERIA. 57 

pelvis by the rhythmic growth of the great utero- 
ovarian plexuses in which it accumulates. This view 
is not, however, at all incompatible with such a func- 
tion of the uterine arteries as has here been suggested 
in the discussion of their peristaltic wave. For, while 
the accumulation of blood in the peri-uterine veins is 
the necessary preliminary, as I have claimed, to its 
evacuation on the free surface of the uterus, a rise of 
tension in the uterine arteries has been shown to be 
necessary to initiate the flow through the rupture of 
endometrial capillaries (Leopold). A rise of arterial 
tension has been demonstrated to precede menstrua- 
tion, first, I believe, by myself, but afterward by a 
pupil of Hegar's, Reine,' and by Fancourt Barnes, of 
England. In such an increase of tension, in which, 
nevertheless, normal rhythm was preserved, it is prob- 
able that a peristaltic vascular wave would be intensi- 
fied, and blood aspired more abundantly to the uterine 
arterioles at the same moment that it had reached its 
maximum of accumulation in the peri-uterine veins. 

I think the hysterical character of at least many 
cases of amenorrhoea is often overlooked. I have 
myself often mistaken it, until the prolonged observa- 
tion of the patient has detected the successive evolu- 
tion of many undoubted hysterical symptoms. It then 
becomes clear that the amenorrhoea is itself an hys- 
terical neurosis. It is putting the cart before the horse 
to think that these symptoms are the co7isequence 
of the amenorrhoea. As well say that acute melan- 
cholia was such a consequence ; and, indeed, gyne- 
cologists are not infrequently guilty of the latter ab- 
surdity. The pathogeny of the cases in question, 
moreover, is made very clear by the fact that hysterical 

' See Volkman's Klinische Sammlung. 



58 SOME CONSIDERATIONS ON HYSTERIA. 

symptoms may be discovered, if looked for, in the 
history preceding the amenorrhcea, as well as in that 
following it. 

It is not claimed here that the vaso-motor spasm 
which is suggested to explain the absence of the men- 
strual flow, and consequent arrest of other menstrual 
processes, is necessarily the only disorder at the basis 
of the amenorrhoea. There may be some direct in- 
fluence of the nervous system upon the processes of 
reproductive growth at the endometrium, ovaries, and 
plexuses. But of such direct influence of the brain 
upon growth there is at present much less known than 
of its indirect influence through the induction of vaso- 
motor spasm ; and the latter explains the phenomena. 
The numerous vaso-motor or sympathetic nerve dis- 
orders which accompany hysterical amenorrhoea, and 
which are absent in purely anaemic or cachectic 
amenorrhoea, are not consequent upon, but co-inci- 
dent with, the disordered uterine function. They are 
the common expression of the same fundamental cause. 

Case XXX.— Unmarried woman, aged twenty-six. Began to 
suffer from dyspepsia, and simultaneously to exhibit profound de- 
pression of spirits and hypochondriacal preoccupation about her 
health. While at Salisbury's Health Establishment, following 
rigid diet for dyspepsia, menstruation ceased, and remained ab- 
sent for two years. Persistence of dyspepsia, very severe for 
eighteen months, then relieved considerably by diet and stomach- 
washing. Then treatment by health-lift, and soon improvement 
in dyspepsia. In two months menstruation returned ; coinci- 
dently dyspepsia disappeared, patient felt quite well, and able to 
eat ordinary diet. A month later symptoms of approaching men- 
struation occurred, but there was a delay of a day or two in flow. 
A single local application of galvanism (made to cavity of cervix) 
was followed on same day by flow. Previous to use of the health- 
lift, electrical applications had caused nausea without having the 
slightest effect upon menstrual symptoms. 



SOME CONSIDERATIONS ON HYSTERIA. 59 

Case XXXI. — Well-developed young woman, aged twenty-five. 
No appearance of anaemia, but to hsmitametre blood-corpuscles 
always below four million ; hsemoglobine, sixty per cent. Men- 
struation always irregular, often at intervals of six months, finally 
of an entire year. During seven years almost constant suffering 
from headaches of all description. For a year, ovarian hyperes- 
thesia, aggravated by walking. Numbness and inability to use 
arms. Often inability to use eyes in reading, etc., for several 
weeks at a time, though eyes quite free from organic defect. In- 
ability for mental exertion ; frequent attacks of mental depres- 
sion. Finally return of menstruation — four times in eight months 
— under combined influence of change of scene and society and 
use of health-lift. Coincidently headache, much relieved, began 
to disappear during long intervals ; all other symptoms entirely 
disappeared. 

Spasmodic tonus or contraction of the unstriped 
muscular fibre of the blood-vessels, has its counterpart 
in the spasm of other unstriped muscular fibre, which 
is so common in hysterics. There is the spasm of the 
oesophagus (globus), of the intestine (cramps), of the 
uterus (dysmenorrhoea). There is, apart from spasm, 
the irregular and precipitate peristaltic contractions of 
the stomach, which result in vomiting ; of the intestine, 
which result in the well-known nervous diarrhoea. It 
is generally accepted that both the tetanic spasm and 
the irregular clonic contractions of unstriped muscular 
fibre imply an excess of nerve-discharges through the 
sympathetic nerve, when this ceases to be sufficiently 
inhibited by the cerebro-spinal axis. The splanchnic 
habitually inhibits the intestine ; its paralysis is fol- 
lowed both by exaggerated peristalsis and neuro- 
paralytic hyperaemia.' 

The facility with which diarrhoea follows, in certain 
persons, upon depressing emotions, indicates that the 
inhibition of cerebral activities suffices to remove this 

' Nothnagel : Studien fiber den Darm. 



6o SOME CONSIDERATIONS ON HYSTERIA. 

inhibitory influence of the splanchnic' Per contra, it 
may be inferred that the splanchnic nerve habitually 
serves to convey inhibitory influences from the brain. 

The constipation of hysterics, which is often so re- 
markably obstinate, could not, consistently with the 
theory advanced in this paper, be ascribed to an excess 
of cerebral inhibition such as causes the constipation 
of organic brain disease. It is more probably associ- 
ated with deficient secretion on the intestinal mucosa, 
through deranged vaso-motor innervation. In severe 
hysteric attacks the stools, when procured, are apt to 
be singularly hard, dry, and black. Tetanic cramp, 
associated with flatulence, interferes with peristalsis. 

Spasm of accommodation of the eye and spasmodic 
action of the muscles of the larynx are phenomena 
which seem to be intermediate between the disorders 
of other voluntary and of involuntary muscular fibre. 

Hysteric aphonia certainly ranks among the hys- 
teric paralyses, and is, in every respect, analogous to 
those of the limbs. If, as assumed by Delavan,^ the 
cortical centre for the inferior laryngeal nerve be near 
the centres for articulation, it cannot be identified with 
them. Paralysis of the vocal cords only by exception 
accompanies aphasia 3; and sounds, whose varying 
timbre would imply varying modulated contraction of 
the laryngeal muscles, can still be emitted when power 
of distinct articulation is lost. Conversely, in hyster- 

^ Nothnagel (loc. cit.) comments on the singularity of the circumstance that 
the large intestine is normally evacuated only once a day. The fact that the 
typical time for this evacuation is the early morning may indicate that during 
sleep, M'-hen cortical inhibition is reduced to a minimum, the irritability of the 
intestinal nerves gradually rises until, upon the stimulus of the first meal, peri- 
staltic contractions attain their maximum of power. 

2 On the Cortical Motor Centre for the Larynx, The New York Medical 
Record, 1885. 

"It did in Delavan's cases. 



SOME CONSIDERATIONS ON HYSTERIA. 6 1 

ical aphonia the power of articulation with the Hps is 
preserved. 

Variations in timbre of the voice are closely as- 
sociated with the emotions. They vary, also, with the 
physical modifications of the reproductive organs, and 
with special mental emotions associated with these.' 
For all these reasons it seems probable that the corti- 
cal centre for the inferior laryngeal nerve is more closely 
connected than the articulating centre with areas for 
sensory impressions, and especially with the terminal 
areas for the centripetal fibres of the utero-ovarian 
nerve. Irritations transmitted in this nerve, or hyper- 
excitation of its cortical centre, might, therefore, be 
expected to somewhat especially affect the cortical 
centre for the laryngeal nerve, altogether inhibiting it 
(hysterical aphonia), or partially so (causing irregular 
innervation of the laryngeal muscles). 

Spasm of accommodation of the eyes has attracted 
a great deal of attention lately as a cause of hysterical 
symptoms, and especially of headache. The neurosis 
of the motor oculi nerve, upon which such spasm de- 
pends, bears a threefold relation to hysteria. 

1. It may be due to organic defect of the eye — 
uncorrected hypermetropia or myopia, astigmatism, 
etc. — and constitute the intermediate event between 
such defect and cerebral symptoms. 

2. It maybe due to a peripheric irritation, and then 
either coincide with cerebral syptoms simultaneously 
caused by this, or be itself the immediate cause of them. 

3. It may be directly caused by the cerebral condi- 
tions of hysteria, of which it is at once an expression 
and an aggravation. 

^ Darwin points out that the primary use of the voice in animals is for the 
attraction of the mate. 



62 SOME CONSIDERATIONS ON HYSTERIA. 

The following case illustrates the second of these 
conditions : 

Case XXXII. — A girl of eighteen fell on the end of her back, 
and soon after developed coccyodynia. A year later, this still 
persisting, she began to have intense spasm of the internal recti 
muscles, associated with visual hallucinations and mental excita- 
bility of undefined character. The coccyodynia was cured by 
galvanism, the spasms of accommodation treated by appropriate 
glasses ; the hallucinations and mental disturbance then disap- 
peared. 

The numerous nuclei of the motor oculi nerve lie in 
the gray matter surrounding the aqueduct of Sylvius, 
and beneath the corpora quadrigemina. Through the 
medium of the latter they are connected with optic 
nerve-fibres ; hence indirectly with the visual centre 
in the cuneus. The proximity of this to the terminal 
areas of the fibres in the sensitive fasciculus ' may ren- 
der it peculiarly susceptible to centripetal irritations. 
Thus in Case XXXII. the irritation caused by the 
blow on the spine, and, later, the permanent irritation 
of Luschka's ganglion, must have been conveyed to 
this cortical region ; thence to the visual centre, caus- 
ing the visual disturbances ; thence probably to the 
third-nerve nuclei, with the effect of exaggerating 
nerve discharges to the internal recti muscles. 

From the foregoing considerations, hysteria appears 
as one of the most profound and far reaching of all 
constitutional diseases, or as one of the most serious 
accidents which can result from utero-ovarian disease 
or other form of irritation peripheric to the nerve- 
centres. It is allied to insanity, as being primarily a 
disease of the fore-brain ; and, further, in many of its 
most peculiar (occasional) symptoms — as amenor- 

^ At the posterior part of the thalamus and internal capsule, turning back to 
the occipital lobes. 



SOME CONSIDERATIONS ON HYSTERIA. 63 

rhoea ; or in perversions of fundamental instincts — as 
that for food, the sexual and the maternal instinct ; in 
its sensory hallucinations, in the predominance of ego- 
tistic consciousness over external perception, in its 
purposeless excitability, depression of effective force, 
suspiciousness of others, correlative with a sense of 
personal inadequacy, etc. This relationship of hyste- 
ria to Insanity is perfectly well recognized by alienists, 
but often overlooked by the general practitioners or 
specialists under whose eyes hysterical symptoms 
usually develop. It is also recognized that hysteria 
may accompany organic brain disease (Seguin), or 
epilepsy ^ (Gowers), or precede insanity ; In such cases 
indicating the beginnings of cortical degeneration 
(Gowers). The relations of hysteria to the degenera- 
tion of stock are again indicated by Its frequent 
family coincidence with tuberculosis.'' 

Profound as are the roots of hysteria, and although 
it be often as Incurable as insanity accompanied by 
cortical wasting, though it be often as tenacious as 
life, or even occasionally fatal, it is, nevertheless, 
usually the lighter form of the neuroses and degenera- 
tions to which It is allied. It is, moreover, not Infre- 
quently symptomatic ; that Is, though the tempera- 
ment may have pre-existed, the serious symptoms only 
date from some curable peripheric or moral irritation. 

Is there any distinction to be made between hysteria 
and neurasthenia ? A distinction is often made, based 
upon the sex and temper of the patient. If this be a 
female, and notably selfish, the case is pronounced 



^ Apart from the so-called hystero-epilepsy, or hysteria major. Gowers on 
Epilepsy, p. 175. 

^ Grasset : Brain, 1884. I have frequently had occasion to note this, or the 
occurrence of hysteria in phthisical families. 



64 SOME CONSIDERATIONS ON HYSTERIA. 

hysteria. If a man, or though a woman, amiable and 
unselfish, the case is called neurasthenia. 

It is difficult to see any reason for distinctions on this 
line ; for, as already pointed out, notwithstanding the 
logical tendencies of the disease toward a most pro- 
found self-absorption, these tendencies are entirely re- 
sisted in a great many cases, simply because the mass, 
educated development, and wealth of organized asso- 
ciations in the fore-brain were such that it resisted 
sensory inhibition sufficiently to maintain, though at 
expense of much suffering, high moral and mental 
character. 

I think the diagnosis of hysteria rests upon two cir- 
cumstances : the presence, in the status or in the 
history of the patient, of psychic symptoms ; or the 
presence of, at a distance from a focus of irritation, 
symptoms improperly called reflex, and only explicable 
by the intervention of a cortical arc, either a sensory 
motor arc, or one exclusively sensory. Hysterical 
aphonia or paraplegia illustrate the first of such arcs ; 
all '^ irradiated " pains illustrate the second. 

Apart from these cases are others in which the 
symptoms remain entirely within the sphere of the 
medulla and spinal cord, which are lacking the dis- 
tinctive fore-brain symptoms of hysteria, which are 
usually attended with circumstances of exhaustion of 
the general nutrition, or localized exhaustion of certain 
nerves, and for which the name neurasthenia might 
more justly be reserved.' 

The cardinal point in the treatment of hysteria 
should be the constant reference to the cerebral nature 
of the disease. This recommendation has indeed long 
passed into common parlance, though based on the 

^ Beard's neurasthenia certainly included hysteria. 



SOME CONSIDERATIONS ON HYSTERIA. 65 

most approximate estimate of the cerebral influence. 
That mental impressions and mental shocks were 
capable of dissipating entire trains of hysterical symp- 
toms, has often been pointed out. The inference has 
too often been drawn that the symptoms were '' imagi- 
nary " and within the control of the patient, while the 
fact that the imagination, the consciousness, the very 
citadel of personal existence, has been invaded by a 
morbid process, cannot fail to threaten paralysis of 
volition and self-control. 

It is in the prophylaxis of hysteria that the widest 
use may be made of moral impressions, and the most 
systematic effort made to organize these into the brain 
as an effective dike against threatened inhibitions. 
Early in life the ego must be, by habit, '' decentral- 
ized," until impressions originating externally to the 
body become as distinct a part of consciousness as 
those generated within it. Not less important is the 
cultivated habit of centrifugal impulses to balance the 
excess of sensibility. Otherwise, though removed 
from the tyranny of the physical sphere, the organism 
remains too predominantly under the influence of 
secondary sensory impressions associated with the 
emotions. When hysteria develops, it implies that 
the mechanisms associated with the inmost individual- 
ity have succumbed to the accidents and calamities of 
life. The prophylaxis demands the construction of a 
personality so robust, the accumulation of resources 
so wealthy, that every misfortune may be resisted 
until the moment of real death. 

In this connection the words of so distinguished a 
neurologist as Eulenberg carry all the more weight, be- 
cause dwelling on facts whose significance seems to be 
so little recognized among his own countrymen. '' The. 



66 SOME CONSIDERATIONS ON HYSTERIA. 

predominance of hysteria among women," he says, " de- 
pends, uhimately, far more upon the social conditions 
to which they are subjected, than upon uterine catarrhs 
and erosions. These conditions combine to arrest 
energy of will and independence of thought in women ; 
to suppress impartial comparison of their own individu- 
ality with external objects ; to restrain or suspiciously 
supervise all impulses to free action ; and especially to 
obstruct and oppose any attempt at emancipation from 
the limits of a narrow and trivial existence. To these 
circumstances are due precisely the most severe, ex- 
tended, and incurable cases of hysteria." ' 

Where the social conditions are favorable, the intel- 
lect normally active, yet for a time inhibited under the 
tyrannous influence of a sensation or an association, 
change of scene certainly has a most extraordinary In- 
fluence upon hysterical patients. The hyper-excita- 
bility of their cerebral sensory centres renders them 
morbidly susceptible to the influence of visual as of 
other centripetal impressions, and to the associations 
generated by these. Hence the material objects in a 
locality where painful events have transpired constitute 
real sources of peripheric irritation, incessantly renew- 
ing the first. In one case that I knew, a young French 
lady received, at six o'clock one afternoon, the news 
of the result of a criminal trial, which. In deciding ad- 
versely to her step-father, broke off a project of mar- 
riage for herself. Every day for a year at the same 
hour, when a certain bell struck, the girl had an attack 
of fever. 

In another case (Case XXXIV.), a woman of con- 
siderable intelligence, but who, for several years, had 
exhibited distinct hysteric symptoms, was thrown into 

^ Nervenkrankheiten. 



SOME CONSIDERATIONS ON HYSTERIA. 6^ 

a. condition of profound mental and physical prostra- 
tion by the death of her mother. This condition was 
complicated by insomnia, and attended by a degree of 
psychic pain which the patient subsequently described 
as '' the tortures of hell." At the end of two months 
the symptoms were unabated, and the attending phy- 
sician began '' to suspect organic disease of the spinal 
cord." The patient was then sent to another city, and 
immediately began to improve. Without further 
treatment than a daily seance of faradization, which 
cured the insomnia, she rapidly recovered. 

When change of occupation and change of interest 
can be added to change of scene the influence is still 
greater. The more areas of the cortex that can be 
awakened to functional activity, the more chance there 
is for resisting sensory inhibition ; the more vaso- 
motor inhibiting power is restored to the cortex, the 
more the intracerebral circulation of impressions is 
quickened, centrifugal currents established, and, if we 
may hazard again the hypothesis already enunciated, 
the more the surcharged sensory centres may be dis- 
charged. 

The foregoing influences all bear upon the mental 
processes of the brain, finally elaborated (it is prob- 
able) in its " latent zones." By affecting these, vis- 
ceral disorders are frequently relieved, not because 
they did not exist before, but because the visceral func- 
tions of the brain in controlling vaso-motor spasm have 
been indirectly modified, and the disorders resulting 
from vaso-motor excitation are therefore controlled. 

After the psychic, the second great function of the 
brain which sustains inhibition in hysteria is the motor. 
Treatment directed to the stimulation of this function 
maybe expected to be beneficial in the same way, and 



68 SOME CONSIDERATIONS ON HYSTERIA. 

for the same reason, as the moral treatment briefly 
alluded to. Many special modes of treatment are 
already in use for hysterical symptoms, whose real 
value probably consists in their common power to 
modify the fundamental condition of hysteria. Thus 
faradization, massage, Swedish movements, active 
gymnastics, horseback, and other non-systematic exer- 
cise, the health-lift, all energize the cerebral motor 
centres.' 

Early in this paper has been quoted Meynert's in- 
genious theory of the development of the power for 
voluntary action, through registration in the brain- 
cortex of impressions or images of movements which 
have been effected involuntarily, through subcortical 
reflex arcs. Now, when a muscle is contracted in- 
voluntarily by the application of a faradic current, an 
impression of the movement may similarly be expected 
to be registered in the motor centres of the cortex. 
An accumulation of such impressions should so stimu- 
late these motor centres as perhaps to enable them to 
escape from the inhibiting influence of the sensory 
areas. 

Faradization was first used in treatment of hysterical 
paralysis. But there is no hysterical symptom to 
which theory, confirmed by experience, does not show 
it to be adapted. In the severe Case XXXIV. insom- 
nia was relieved by it, after having resisted poisonous 
doses of narcotics. 

When the current is applied over the surface of the 
body without contracting the muscles, the effect on 
the cortex of registering a muscular contraction cannot 

^ Other effects are, of course, produced through the increased inspiration, 
circulation, and muscular nutrition, but these are apart from the special prob- 
lem under consideration; 



SOME CONSIDERATIONS ON HYSTERIA, 69 

be obtained. The application is, however, often bene- 
ficial, except where there is hypersesthesia of the sur- 
face ; for this is usually aggravated by faradization. 
Can it be inferred that in this case the ingoing electri- 
cal current, or rather the nerve current it excites, 
inhibits the excitation of the sensory centres of the 
brain ? 

Case XXXV. — This fragile patient has already been mentioned 
as the subject of transient albuminuria. While feeling very weak 
and wretched, with pains in back, bowels, and uterus, she had a 
seance of faradization lasting half an hour. One electrode was 
placed at the nape of the neck, the other passed over the abdo- 
men. The patient at once began to feel better, and during two 
days following was most remarkably improved, all pains disap- 
pearing. 

Such cases could easily be multiplied. They are in 
every one's experience, but the results are very vari- 
ously interpreted. Weir Mitchell ' only mentions the 
local effect upon muscles supposed to become better 
nourished when forced to contract by electricity. The 
common idea seems to be that the electrical current in 
some way takes the place of nerve-force when the lat- 
ter is deficient ; an idea that is certainly erroneous. 
It is true the faradic current can replace the nerve-cur- 
rent in liberating energy from a muscle-cell, just as, 
under certain circumstances, mechanical stimulus can 
do the same thing. The improvement of non-paralytic 
symptoms noticed in the hysterics who do respond 
favorably to faradization implies, however, central 
stimulation. The current directly stimulates the nega- 
tive, indirectly the positive, work of the nerve-centres 
to which it is brought. The " strengthening " effects 
noticed, therefore, partly indicate increased negative 

* Fat and Blood. 



70 SOME CONSIDERATIONS ON HYSTERIA. 

work throughout nerve-centres (in the foregoing case, 
probably chiefly in the medulla), but there is also 
partly increased positive work consequent on this ; 
thus, in sensory centres, liberation or discharge of 
energies in a centrifugal direction. 

Massage, Swedish movement-cure, and systematic 
gymnastics are all directed toward the exaltation of 
deficient motor force. In passive massage, while the 
surface friction increases the mass of centripetal im- 
pressions, in a manner analogous to surface faradiza- 
tion, the passive contraction of the muscles by the 
movements of the limbs may be supposed to register 
impressions in the cortex, as in the performance of re- 
flex acts. 

When the patient is incited to resist passive move- 
ments by voluntary effort, as in the Swedish move- 
ment-cure, a higher degree of stimulus of cortical 
centres is effected. The intracerebral nature of this 
higher stimulus approximates the action more to nor- 
mal action. Finally, in active gymnastics, the stimu- 
lus is entirely voluntary, the action entirely normal. 
The method, which cannot be utilized at the begin- 
ning of treatment of hysterical paralysis, is inestimable 
in the treatment o^ all other conditions. Theoretically, 
voluntary muscular effort, the physical correlative of 
mental volition, should be, with it, the cardinal re- 
source in the treatment of hysteria ; for it addresses 
itself to the fundamental condition of the disease — 
the depression of motor function below the level of 
sensory function ; and it tends to restore the normal 
centrifugal direction of intracerebral nerve-currents. 

I was led to formulate the above statement thus pre- 
cisely, from observation of the special mode of mus- 
cular exercise afforded by the Butler Health Lift, I 



SOME CONSIDERATIONS ON HYSTERIA. /I 

first tried this in some cases of amenorrhoea, not at all 
with the view I at present entertain, but for the pur- 
pose of increasing blood-pressure in the pelvis and 
thus restoring the menstrual flow. The two cases in 
which this method received a fair trial have already- 
been mentioned. 

In Case XXX. the menstruation had been absent for two years, 
although up to that time it had been quite regular ; the patient was 
only moderately anaemic, and retained excellent muscular strength, 
as shown by her capacity to speedily attain a lift of ninety pounds. 
The patient was also constantly occupied in family duties, espe- 
cially in waiting upon a sick father, so that moral and even 
motor centrifugal currents might seem to exist in sufficient abund- 
ance. But she suffered from prolonged dyspepsia (though, as 
shown by the stomach-washing, very rarely from gastric catarrh), 
from constipation and flatulence, and the psychic symptoms of 
depression and hypochondria had been extremely marked. It 
was while these were at their maximum that the amenorrhoea 
began ; they had much subsided when I first had charge of the 
case, and the dyspepsia was a good deal relieved by the stomach- 
pump treatment. This was interrupted, however, and by my 
advice the patient hired a health-lift and exercised on it regularly. 
At the end of a month the dyspepsia was much improved, and 
the patient felt in every respect better. At the end of two months 
she menstruated. She then was able to return to a mixed diet. 
The third month there was a little delay, only a day or two, in 
the return of the menstrual flow ; a single local application of 
galvanism brought it on. This had previously been tried with no 
effect but the production of nausea. 

In Case XXXI. the first improvement in the patient's health, 
after three years of almost constant suffering, was observed dur- 
ing a summer spent at Lake Mohonk, where the patient practised 
rowing. During these three years menstruation had occasionally 
occurred spontaneously, and had several times been brought on 
by local applications to the uterus of laminaria tents, and iodine 
internally. These applications, however, often failed, and when 
they succeeded in determining a uterine hemorrhage, the patient 
usually felt worse after them, with more headache and prostra- 
tion. The month preceding the visit to Lake Mohonk an iodine 



72 SOME CONSIDERATIONS ON HYSTERIA. 

application had been followed, not by menstruation, but by a four 
weeks' leucorrhoea. It was noticeable that during this period, as 
with any other peripheric irritation which lasted a short time, the 
patient was relieved from headache ; but she claimed to feel 
"wretchedly," and expressed the greatest horror of the experience. 
In September the health-lift was begun ; in October the patient 
menstruated, exactly a year from the last date. She subsequently 
menstruated in February, April, June, and July. Coincidently, 
the headaches greatly diminished in frequency and intensity, 
ovarian hypersesthesia entirely disappeared, and the patient felt 
distinctly and " immensely better." 

That in this last case the improvement was not due 
to the fact of menstruation was indicated by its ab- 
sence when the menstruation, was brought on by other 
means. The spontaneous appearance of the flow dur- 
ing the use of the lift was an indication, not a cause, 
of improvement. The patient always felt better dur- 
ing two or three weeks preceding a spontaneous men- 
struation, and always worse after one, whether spon- 
taneous or artificial. During the month which fol- 
lowed the second menstruation after the health-lift, 
the patient was wretched, with severe headache ; but 
after the last two menstruations, remained well. 

I think the details show in this case, as in the other, 
that with the revival of the motor function of the cor- 
tex its inhibiting power over the vaso-motor centres 
was revived, the vaso-motor fibres in the utero-ovarian 
nerve were restrained from their excess of action, and 
an arterial afflux of blood permitted to the endomet- 
rium. Probably, also, the nutritive processes of 
growth on the endometrium, the ovary, and the plexus 
were coincidently permitted to resume their course. 

In Case XXXII. there was no amenorrhoea, but the patient, 
who had been excessively hysterical previous to the replacement 
of a retroflexed uterus, continued after this to retain some hyster- 
ical symptoms. She remained rather weak, and her power of 




Fig. 9.— After three lifts. (One 



SOME CONSIDERATIONS ON HYSTERIA. 73 

walking was much interfered with by a pain occupying a limited 
area of the right vaginal wall, apparently in a branch of the pudic 
nerve. This pain was ascribed by the patient to the pessary, an 
instrument which had greatly excited her imagination. It seemed, 
indeed, to be the last remnant of the multiform distress that had 
first attended the most careful use of the pessary, and certainly 
had nothing to do with the latter. Under the use of the health- 
lift this pain entirely disappeared, the patient became able to 
walk, and was in every respect well. 

It Is noticeable that in all three of these patients 
electricity, however applied, invariably aggravated 
whatever symptom it was applied for. 

I am prepared to believe that the health-lift will 
prove an invaluable remedy in the cases in which it 
can be tried, and when it is used efficiently. It is rare 
that this can be done by visits to a physician's office ; 
the patient should buy or hire a lift, and have it at 
home for daily use. Each session occupies an hour, 
since the lift must be handled four times, at an inter- 
val of fifteen minutes between each lift, occupied by 
complete repose. Either one or two sessions a day, 
according to strength of patient, should be prescribed. 

Sphygmographic tracings were taken of several pa- 
tients, not always with uniform result. Figs, i and 2 
were taken from a women, aged thirty-seven, suffering 
from hysterical pain at epigastrium, hypogastrlum, left 
ovarian region. In track of Illo-hypogastric nerve, over 
left hip, and at point of emergence of two upper sacral 
nerves. Pelvic organs perfectly healthy. 

The trace just before the lift is irregular in the in- 
dividual pulsations ; shows numerous elasticity oscilla- 
tions, almost absence of respiratory curve. This was 
taken after the patient had already used the lift several 
times, the last half an hour before. The trace taken 
immediately after shows an enormous development of 



74 SOME CONSIDERATIONS ON HYSTERA. 

the percussion stroke, part of which may be due to 
increased force of cardiac contraction, but part cer- 
tainly to diminished tension, as the Hne collapses (in 
the first three figures) almost immediately from the 
summit. The respiratory line rises, showing the in- 
creased depth of respiration. 

Figs. 3, 4, and 5 (from Case XXXII., with per- 
sistent neuralgia in branch of pudic nerve) show a de- 
cided increase of tension from use of lift. 

Figs. 6 and 7 show a marked development of the 
percussion stroke and a rise of the respiratory base- 
line. This patient had a (corrected) retroflexio uteri, 
and was recovering from a prolapse of the ovary, 
but was rather free from hysterical symptoms. 

Figs. 8 and 9 are from a girl, aged sixteen, who 
had never menstruated, and was suffering much from 
headache. The pulse developed considerably by the 
lift, tidal wave and tension increasing. The girl's 
health improved very much during the fortnight she 
used this, coincidently with walking, but she then, for 
some unknown reason, ceased attendance. 

The increased heart-action noticed in all these traces 
was the direct result of the muscular effort. The col- 
lapse of the line in Figs, i and 2, as well as the in- 
creased tidal wave in the other figures, both imply 
diminished vaso-motor tension — in the first case simply 
lowering the resistance, in the other permitting dilata- 
tion of blood-vessels. 

It is to be noted that if this is not accomplished, 
and the arterioles remain contracted while the energy 
of the cardiac contraction is increased, there will be 
fatigue, cardiac distress, and palpitations. Undoubt- 
edly such cases will present themselves in practice. 
The danger can be avoided by the careful graduation 



SOME CONSIDERATIONS ON HYSTERIA. 75 

of the weight to be Hfted, avoiding such as shall too 
suddenly increase the force of the cardiac contraction. 
I have known horseback riding to restore an inter- 
rupted menstruation as efficiently as the health-lift. 
Between the latter, active gymnastics, and horseback 
exercise, it is possible that there may be little to 
choose. Still, as with all other remedies, a case 
which resists one will often be found to yield to 
another apparently quite analogous. The health-lift 
is much cheaper than horseback riding, and it has this 
advantage over calisthenics, that the am.ount of force 
exercised Is much more independent of the patient's 
will. When the movement to lift has begun, It must 
be finished, and with the same weight ; must always 
be performed with the same degree of force. But it 
is very possible for dumb-bell and other callsthenic ex- 
ercise to be carried out so listlessly and feebly that no 
effect Is produced at all. All the foregoing methods 
of motor treatment are much superior to walking ; of 
which, in a great many cases, the patient is quite 
incapable. Walking may be found to increase ovarian 
hyperaesthesia, or headache, or backache, or any other 
symptom. The effect of the health-lift in Increasing 
the force of the circulation, and hence the amount of 
oxygen carried to the tissues, and especially the brain, 
may be secured by another physical apparatus, the Wal- 
denburg machine for compressed air. I have obtained 
the most prompt and marked relief to hysterical dysp- 
noea and intercostal pains by this method, where 
there was not a trace of pulmonary disease. One 
patient purchased an apparatus, and to her daily use 
of it, for a year, seemed chiefly attributable the relief, 
not only of the respiratory symptoms, but of many 
others from which the patient had suffered for seven 
or eight years. 



76 SOME CONSIDERATIONS ON HYSTERIA. 

This winter I have appHed the same treatment to 
an anaemic girl (Case XXXV.), a subject for many 
years to sHght epileptiform attacks, resembling petit- 
mal, and also to neurotic symptoms, such as Gowers 
calls '' post-epileptic hysteria " ; the principal being 
severe nervous headaches, mental inability, and sense 
of universal fatigue. The inhalations of compressed 
air did not diminish the number of epileptiform at- 
tacks, though these were greatly controlled by nitrite 
of amyl. But the improvement in the hysterical 
symptoms was very marked, so much so that the 
patient was ready to believe herself on the high road 
to complete recovery. The relief was always imme- 
diate, and especially after a petit-mal attack. 

It is to be presumed that the increased amount of 
oxygen forced into the lungs under pressure relieves 
the '' dyspnoeic " condition of the brain-tissues induced 
by vaso-motor spasm. 

The effect of electricity upon hysteric pain has 
been already discussed. In this discussion has been 
pointed out the variableness of this influence. This 
might be inferred from the complex action of elec- 
tricity, part of which may fall in the desired direction, 
another part just in the reverse. Thus the passage 
of the constant current through a nerve tends to lower 
its excitability, and ultimately paralyzes it ; the anode 
depresses, the cathode exalts, the excitability of same 
nerve ; the centripetal impression sent to nerve-centres 
first increases their negative work, chemical synthesis, 
and storage of force ; muscular contractions by fara- 
dism or interrupted galvanism divert nerve-energy from 
sensory centres. It is evident that some of these ef- 
fects tend to antagonize pain, yet the centripetal excita- 
tion of the sensory centres should tend to increase 



SOME CONSIDERATIONS ON HYSTERIA. 77 

both pain and its cause in the existing hyper-excitation 
of these centres. Where the latter is very great, any 
form of electricity does harm. In proportion to the 
more localized diffusion of the pain, electricity seems 
to do good, though with many exceptions. For gen- 
eral action faradism is decidedly preferable to galvan- 
ism. Galvanism may sometimes locally overcome 
vaso-motor irritation. 

All modern studies of hysteria tend to relegate 
drugs to the background in the treatment. The array 
of antispasmodics — musk, assafoetida, valerian, am- 
monia, etc. — which figure even in Briquet's treatise, 
are to-day utilized only for occasional and sympto- 
matic treatment. This really still leaves a large sphere 
of usefulness for these remedies in the management of 
these often exquisitely unfortunate patients. The 
treatment of vaso-motor dysmenorrhoea especially 
calls for suitable '* antispasmodic " remedies, while 
musk has extraordinary value In the attacks of pro- 
found prostration which are common. The value of 
opium in hysterical vomiting, of digitalis in hysterical 
irregularity of the heart's action, of ergot in the pelvic 
congestions which so often initiate or maintain hyster- 
ical conditions, need only be mentioned here. 

The internal use of strychnine should be classed 
among agents which act directly on the motor system. 
It diminishes resistance' to the transmission of impres- 
sions through the cord. 

It is a matter of course that the treatment of anaemia, 
by meat, iron, cold pack, shower bath, mountain air, 
is often indicated in the management of hysteria, and 
when indicated becomes of the utmost importance. A 
richly meat diet is nearly always indicated, for the rea- 
son that the ingestion of albumen in abundance is the 



78 SOME CONSIDERATIONS ON HYSTERIA. 

most powerful agent for increasing the absorption of 
oxygen. Yet the same persons who habitually require 
meat may from time to time require to completely ab- 
stain from it for a few days, during attacks of (liver ?) 
indigestion associated with copious deposits of sand in 
the urine. There is an hysteria whose basis is lithae- 
mia — form not infrequent in men as well as women. 
But there is also an intercurrent gastro-hepatic indi- 
gestion that seems to be associated with vaso-motor 
congestions of the liver, and consequent interference 
with the functions of the gland in the elaboration of 
urea. It is probable that transient diabetes would 
often be discovered if looked for, as in the case of 
severe neurosis already mentioned. 

The association of obesity with hysteria is very fre- 
quent. Weir Mitchell observes that it is much more 
difficult of treatment than the hysteria of thin people. 
The necessity for meat diet, with restriction of liquids, 
is here as great as in the cases where the obesity is 
associated with organic heart and kidney disease.^ 

The nutrition of the nerve-centres is impaired in 
proportion to the deposit of nutritious material in 
cellulo-adipose tissue, and the permanent hyperaemia 
of this. 

The two following cases strikingly illustrate the ef- 
fect upon hysterical symptoms — in one case including 
amenorrhoea — of appropriate diet, with massage and 
hydrotherapeutic treatment. 

Case XXXVI. — Married, three or four children ; large and 
very fat woman, weighing two hundred pounds. Since increase 
of weight, during a year, profound prostration of strength, with 
hysterical depression, crying, trembling of limbs on walking, pal- 
pitations on exertion. Heart probably overlaid with fat ; no other 

^ See Oertel : Therapie der Kreislauf's Stoning, 1884. 



SOME CONSIDERATIONS ON HYSTERIA. 79 

disease. Placed on meat diet, gluten bread, liquids restricted ; 
tincture nux vomica, cold pack, with massage and cutaneous 
faradization three times a week. Great improvement in a month. 
In six months patient had lost forty pounds and was feeling quite 
well. Diet continued for a year. 

Case XXXVII. — Married woman, aged thirty ; three children. 
Rather short woman, but weighed two hundred and forty pounds. 
Psychic depression, palpitations, amenorrhoea for seven months. 
Packs, massage, meat and gluten bread diet. Immediate and 
striking improvement. Reduction in weight averaged three 
pounds a week. Menstruated six weeks after beginning treat- 
ment, and thence regularly. Spirits improved at once. Treat- 
ment continued five months ; patient then quite well. At close 
of year weighed one hundred and fifty-eight pounds. 

The removal of the ovaries for intractable hysteria 
is indicated in two different classes of cases : (i) 
Where their diseased condition is a source of masses 
of nervous impressions, improperly called reflex, which 
irritate the sensory centres of the brain and determine 
the series of consequences which follow on this irrita- 
tion ; (2) where the ovaries are normal, but the ir- 
ritability of these same centres, acquired in other 
ways, has become such that the normal impression 
generated in the menstrual processes causes intoler- 
able irritation. I have known of two cases where 
Battey's operation was performed with entire relief to 
an immense train of morbid symptoms, which in one 
case included eight years' paraplegia. In neither 
did the ovaries appear abnormal to the naked eye ; 
in one which I was able to examine by the microscope, 
the morbid changes were very slight. 

The first case has been reported by Dr. Munde,' 
who performed the operation, and has been already 
mentioned in this paper. 

Theoretically, it is perfectly logical, in cases of 

^ New England Medical Monthly. 



So SOME CONSIDERATIONS ON HYSTERIA. 

hyperexcitability of cerebral sensory centres which 
have resisted all other means of treatment, to remove 
the ovaries in order to cut off from these centres the 
large mass of centripetal impressions which reach 
them when the rhythm of menstrual processes is 
going on. It has been abundantly shown that this 
operation is not often immediately successful ; either 
because menstruation persists, or because the nervous 
phenomena persist in the absence of menstruation. 
Both, however, tend to subside with the lapse of time, 
and I think that it is only after two years that we 
should, if at all, call the operation a failure. I have 
known several cases where the morbid symptoms 
persisted nearly to this time, but disappeared after- 
ward. 

The facility of abusing the operation is, however, 
obvious ; but the statistical discussion of its value 
does not lie within the scope of this paper. 



II. 

TUMORS OF THE BRAIN. 

The symptoms caused by tumors of the brain are 
due, first, to irritation or destruction of the portions 
of the nerve-tissue in which they are embedded, or 
near to which they lie ; second, to pressure exercised 
upon the entire contents of the cranium — nerve-tissue, 
blood-vessels, and lymphatics. The first class of 
symptoms are common to tumor, and to all other 
circumscribed lesions of the same locality, thus espe- 
cially patches of chronic softening. The second class 
are common to all conditions in which the intracranial 
space is encroached upon ; such are extra- as well as 
intra-cerebral tumors, morbid products within the 
brain, which differ considerably from neoplasms 
proper, and, finally, abscesses and aneurisms. Thus, 
the investigation of the case of any patient exhibiting 
cerebral symptoms demands that we decide : First, 
whether these are caused by a new growth of any 
kind, which is encroaching upon the cranial cavity ; 
second, this being admitted, what is the nature of the 
growth ; third, what is its precise locality. 

The prognosis must then be framed according to 
the fact, the nature, and the seat of the growth ; and, 
finally, the (very limited) indications for treatment 
must be considered. 

Symptoms Indicating the Existence of an Intra- 

* Reprinted from Wood's Reference Handbook of the Medical Sciences. 

8i 



82 TUMORS OF THE BRAIN. 

CRANIAL Growth. — These are of two kinds : those 
belonging to the perversion or aboHtion of cerebral 
function, and those indicating a rise of intracranial 
pressure. The first are the focal, the second the 
diffused symptoms (Griesinger). It is this second 
class of symptoms which are of the most importance 
in distinguishing between tumor and other cerebral 
lesions, and they may therefore be considered first. 

Diffused Symptoms. — These are headache, vertigo, 
vomiting, general epileptiform convulsions, apoplecti- 
form attacks, psychic disturbances, and choked disk. 

Headache is one of the earliest and most constant 
symptoms of intracranial tumor. It is also often one 
of the most severe, and, by its persistence and in- 
tensity, may be usually distinguished from cephalalgia 
of other causation. It may precede all other symp- 
toms of the disease for some time, and it is then that 
some absolutely pathognomonic characteristic would 
be most desirable, but is hard to find. In a certain 
number of cases the seat of the headache corresponds 
to the seat of the tumor ; this is oftenest the case with 
tumors, intra- or extra-cerebral, which occupy the pos- 
terior cranial fossa. Even here, however, the pain is 
sometimes frontal. Localized percussion will some- 
times greatly intensify the pain at a particular point ; 
and this may be found to correspond to the seat of 
the tumor. The headache is often periodic, and then 
is easily mistaken for an apyretic malarial attack. 
This is especially the case when a frontal headache 
seems to imitate brow-ache. On the other hand, 
occipital headache may simulate the cervico-occipital 
neuralgia of gouty persons. The diagnosis may be 
facilitated in either case by careful exploration along 
the track of the nerve. Nocturnal headache resembles 



TUMORS OF THE BRAIN. 



83 



the syphilitic cephalalgia ; and the question is rendered 
all the more difficult from the fact that brain tumors 
are frequently of a syphilitic nature. 

Although so prominent a symptom when it exists, 
headache is by no means always present. It was 
absent in one hundred and forty-eight out of two 
hundred and seventy-four cases analyzed by Ball and 
Krishaber. By combining the tables of Ladame and 
of Bernhardt (the first summing up all cases published 
earlier than 1868 ; the second, those between that date 
and 1880), we can construct the following table, show- 
ing the proportion of cases of headache with cerebral 
tumors of different localities : 



TABLE I. 



Seat. 


No. of 
cases. 


No. with 
headache. 


Per cent. 


Cerebral peduncle 


10 


4 


40 


Basal ganglia . 








41 


19 


46 


Coriex 








74 


37 


50 


Medulla . 








28 


16 


57 


Cerebral lobes 








196 


129 


66 


Pons 








56 


37 


^1 


Cerebellum 








ig6 


150 


77 


Corpora quadrigemina 








13 


9 


69 



This table helps to confirm the inferences that 
might be drawn from the physiology of pain. It is 
rarely to be attributed to irritation of sensory centres ; 
but rather to the stretching of the dura mater, with 
its rich supply of sensory nerve-filaments from the 
trigeminus. As some degree of stretching always 
takes place, no matter what the seat of the tumor, 
headache is always imminent, but it may not manifest 
itself if the^ tumor grows very slowly, and makes way 
for itself by gradual compression of the brain-sub- 
stance, and displacement of its fluids. On the other 
hand, the pain is most certain to occur, and also to be 
most violent, when the tumor grows in the cerebellum 



84 TUMORS OF THE BRAIN. 

under the tense fold of the tentorium ; it is least likely 
to occur when room is left for the expansion of the 
growth at the interpeduncular space. In the pons 
and medulla, direct irritation of the trigeminus may 
add a special liability to pain. The great liability to 
headache with tumors of the corpora quadrigemina 
may perhaps be due to their intimate connections with 
the cerebellum. In the cortex, only half the cases were 
attended by headache ; this probably being due to the 
tendency of the tumor to grow downward, and thus 
to relieve the tension of the dura. The periodicity in 
the pain is undoubtedly associated with fluctuations 
of the circulation, always liable to be diurnally periodic. 
An initial headache often disappears when paralysis 
sets in ; probably because, by that time, a zone of 
softening has usually developed around the tumor. 
The intensity of the pressure is at first either partially 
or entirely relieved ; headache may set in, if the tumor 
suddenly assume a more rapid rate of growth ; it 
necessarily subsides at the appearance of the terminal 
symptoms of drowsiness and comatose apathy ; the 
pain being blunted, like other signs of irritation, in 
the general depression of the sensibility. 

Vertigo is a prominent symptom of any organic 
brain disease, and although frequently present with 
tumor, is far from characteristic of it. It is probably 
always associated with direct or indirect irritation of 
those portions of the brain which are concerned in 
equilibration ; and it agrees well with this presump- 
tion that vertigo so much more frequently occurs with 
tumors of the cerebellum than with those of other 
parts of the brain. Other ** space-encroaching " le- 
sions, e. g.y abscesses, so situated as to afTect the 
middle or internal ear, may cause vertigo by the same 



TUMORS OF THE BRAIN. 85 

mechanism as that which is brought into play in ear 
disease proper — namely, by excitation of the auditory 
nerve. As the central fibres of this nerve have been 
traced to the cerebellum, it seems probable that the 
sensation of vertigo, whether cerebral or aural in ori- 
gin, is always finally produced by the same mechanism. 
The third diffused symptom, vomiting, follows the 
same law of predominance as headache and vertigo — 
namely, it is much more frequent and severe in tumors 
of the cerebellum than in those involving some other 
portion of the brain, with the exception of the corpora 
quadrigemina, where the liability is at the maximum. 

From the following table it appears that vomiting 
is a much less frequent symptom than headache, but 
follows exactly the same order of predominance, ex- 
cept in respect to the centrum ovale. This is because 
the vomiting is partly due to the same cause as the 
headache — namely, the extreme tension of the ten- 
torium. Extreme tension does not, however, always 
cause vomiting. 

Case, by King {Brain, October, 1882) : Two tumors, one on 
right side of pons extending to left middle peduncle of the cere- 
bellum, the second embedded in the left side of the floor of the 
fourth ventricle, convolutions flattened, much serum in ventricles, 
showing extreme intracranial pressure ; but optic neuritis devel- 
oped only after attacks of coma. Headache, but no vomiting. 

The immediate cause of vomiting is supposed to 
be always the excitation of a vomiting centre in the 
medulla ; and this can be brought about by pressure 
transmitted from any part of the brain. This pres- 
sure is, however, more direct when exercised from 
some point in the posterior cranial fossa ; hence a 
second reason for the intensity of the symptom in 
cases of tumor of this locality. 



86 



TUMORS OF THE BRAIN. 

TABLE II. 



Seat of Tumor. 


Headache. 


Vomiting. 


Convulsion. 


Choked Disk (Bernhardt alone). 


Cerebral pedunc 
Cerebral lobes 
Basal ganglia 
Cortex . . . 
Pons . . . 
Medulla . . 
Cerebellum . 
Corp. quad. . 


le 




Per 
Cases, cent. 

4 40.0 
129 66.0 
19 46.0 
37 50-0 
37 67.0 
16 60.0 
150 83.0 
9 69.0 


Per 
Cases, cent. 

36 18.5 
8 19.5 
18 24.0 
15 27.0 
12 40.0 
75 38.5 
8 61.0 


Per 
Cases, cent. 

2 20.0 
49 25.0 

7 27.0 
20 28.0 

2 5.0 

2 6.0 
18 9.0 

I 8.0 


Amaurosis. Vision intact. Total. 

Per Per Per 
Cases, cent. Cases, cent. Cases, cent. 

15 in 124 12.0 12 in 124 10. = 27 in 124 21.0 

_ 2 in 26 8.0 = 2 in 26 7.0 

5 in 57 II. 5 5 in 57 9.0 = 10 in 57 17.0 

4 in 30 13.0 2 in 30 7.0 = 6 in 30 20.0 

2 in 21 90= 9.0 

18 in 90 20.0 13 in 90 14.0 = 31 in 90 34.0 

5 in II 45.0 I in n 10. = 6 in 11 54.0 


Total . . 






423 in 568 
cases = 74 
per cent. 


172 in 568 
cases = 30 
per cent. 


91 in 568 
cases = 16 
per cent. 


82 in 362 cases = 22 per cent. 



Epileptiform convulsions constitute a fourth diffused 
symptom, which is very characteristic of tumors of the 
brain. Their causal relations to increased intracranial 
pressure has been strikingly shown by Leyden's ex- 
periments. In these, pressure was directly applied to 
the brain of animals previously trepanned for the pur- 
pose. Convulsions occurred as soon as the pressure 
had risen to 1 30 mm. of mercury. Pressure, however, 
is only one of the mechanisms by which convulsions 
may be excited. Kussmaul's experiments, made many 
years ago, showed that sudden anaemia of the brain, 
such as might be induced by copious hemorrhage, was 
invariably followed by convulsions. The predomi- 
nance of convulsions in cases of brain tumor, accord- 
ing to the locality occupied by the latter, does not 
follow the law which is applicable to symptoms trace- 
able to increased pressure, for convulsions occur 
oftenest in cases of tumor of the cortex and cerebral 
lobes, presumably of the portions of the centrum ovale 
which lie immediately beneath the cortex. General 
convulsions, therefore, like local spasms, are rendered 
imminent by direct excitation of the motor tracts. 
Curiously enough, convulsions are almost excluded 
from the symptomatology of the pons, though this re- 



TUMORS OF THE BRAIN. 87 

gion, which is traversed in every direction by motor 
tracts, probably contains the convulsing centre. But 
apparently the properties of the centre become abol- 
ished before they can be effectually irritated. This 
absence of convulsions, when certain positive signs are 
present at the same time, is of real value in localizing 
a tumor in the pons. 

As the convulsion is not proportioned to the locality 
of greatest tension, so it stands in no relation to the 
time at which tension is greatest. It occurs as an 
initial symptom, or during the active period of the 
disease ; but it usually disappears, with other irritative 
symptoms, in some other manner toward the close, 
when intracranial pressure is at its maximum. Sud- 
den variations in such pressure, caused by fluctuations 
of the circulation, seem to be the essential proximate 
cause of the convulsions of brain tumors. The form 
of the convulsion does not differ from that observed in 
idiopathic epilepsy, and the diagnosis between tumor 
and epilepsy is often difficult. It can only be made 
by means of the concomitant symptoms. 

Apoplectiform attacks occur with brain tumors, and 
may, though rarely, be the first symptom and followed 
by paralysis or paresis. It is extremely difficult, then, 
to distinguish the case from one of ordinary cerebral 
hemorrhage. Hemorrhage into or around the tumor 
is a frequent cause of apoplexy, and thus may first 
reveal the existence of a tumor hitherto latent ; or it 
may occur incidentally among phenomena already 
well defined and recognized. Finally, the apoplectic 
attack may usher in the terminal period ; the patient 
never completely recovering, but passing into a sopo- 
rose condition and finally into coma. The apoplectic 
ictus is not invariably associated with hemorrhage ; 



88 TUMORS OF THE BRAIN. 

it may be due to sudden alterations of intracranial 
pressure, by which the functions of brain-tissue are 
temporarily suspended, as after concussion. 

Psychic Changes, — The earliest is usually an ex- 
treme irritability, which contrasts with the lachry- 
mose emotionality characteristic of softening of the 
brain. Occasionally this culminates in attacks of 
maniacal excitement ; oftener, however, the patient 
suffers from melancholic depression, and gradually 
becomes more and more apathetic and taciturn. 
This taciturnity, which is a diffused symptom, must 
be distinguished from true aphasia. As in all mental 
disturbances, the memory fails. Dementia may pre- 
cede death for some time, especially if epileptic con- 
vulsions have been severe. 

Case VII., by Mills : Attacks of mania at intervals. Tumor 
occupies occipital and postero-parietal gyri. 

Case, by Hunt : Speech mumbling, thick, no wrong words, 
mental confusion, drowsiness, loss of memory. Tumor occupies 
angular and supramarginal gyri. 

When tumor complicates a diffused meningo- 
encephalitis, the mental symptoms are attributable 
rather to that. 

Case, by Magnan, {Brain^ 1^79) '- Angiolithic sarcoma (psam- 
moma), reducing ascending parietal gyrus to one third its volume, 
associated with diffuse meningo-encephalitis ; epileptiform con- 
vulsions for eight years ; intellectual faculties impaired ; loss of 
memory and moral sense ; mania, dementia. 

The following case is remarkable for the short 
duration of the symptoms : 

Case, by Bristowe (Brain^ 1884) : First symptoms fourteen 
weeks before death. Intelligence early impaired, after headache 
and right hemiparesis. With progress of paresis patient became 
stupid, drowsy, finally comatose. Tumor in anterior part of 
corpus callosum. 



TUMORS OF THE BRAIN. 
TABLE III. 



89 







Intelligence Disturbed. 


Intelligence 

Normal. 


Seat of tumor. 


Mental 
depression, 
apathy, loss 
of memory, 
imbecility. 


Hallucina- 
tions. 


Delirium or 
mania. 


Drowsiness or 
stupor. 


Total. 




Medulla, 29 cases . 
Cerebellum, 162 cases 
Cortex, 57 cases . 




Cases. P. cent. 

6 20.0 

48 29.0 


Cases. P. cent. 
2 7.0 
I ... 


Cases. P. cent. 
2 7.0 
6 3.0 


Cases. P. cent. 
I 3-5 
9 5-0 


Cases. P. cent. 
II 38.0 

64 39-0 

28 49.0 

29 51.^ 
21 52.0 

115 60.0 

6 lo.o 
19 33.0 

10 77-0 


Cases. P. cent. 
18 62.0 
98 60.0 


Pons, 56 cases . . . 
Basal ganglia, 40 cases 
Lobes, 192 cases . . 




27 480 
18 45.0 
90 47.0 

1 ... 
6 lo.o 
9 15.0 

2 3-0 
4 30-0 


I ... 
I ... 

9 4-0 

I ... 


2 ... 

" 5-5 

2 ... 

2 15.0 


I ... 

5 2.5 

7 12.0 
4 30-0 


27 48.5 
19 47.0 
77 40-0 


Frontal .... 
Parietal .... 


II 19.0 
17 29.5 

3 23-0 


Temporal . . . 
Corp. quad., 13 cases 



It Is extremely noticeable from Table III. that the 
liability to perversion of intelligence is not at its 
maximum when the tumor is seated at the cortex, 
nor when a cortical tumor is In the frontal lobes. 
Cortical tumors stand third from the bottom of the 
scale, In this respect ; the highest place is occupied by 
tumors of the corpora quadrigemina, seventy-seven 
per cent. A relative infrequence of mental disturb- 
ances Is observed in tumors of the medulla and pons. 
On the other hand, the high percentage of such dis- 
turbances in tumors of the centrum ovale may proba- 
bly be, at least In part, attributed to their Influence 
upon the cortex. To such influence must, in last 
analysis, all psychic perversions be ascribed ; and the 
high proportion of cases In which these are present 
with tumor In any locality of the brain, is explained 
by the extreme sensitiveness of the cortical substance 
to disturbance of the intracranial pressure from what- 
ever point diffused. Psychic symptoms, of one kind 
or another, are seen to be extremely frequent In 
tumors of the brain, being present in about half the 



90 TUMORS OF THE BRAIN. 

cases. Their presence, therefore, materially aids in 
establishing the diagnosis. 

Choked Disk. — This symptom, when present, is 
more nearly pathognomonic, than any other, of cere- 
bral tumor. The phenomenon of the choked disk 
has been regarded as the expression of two different 
morbid processes — the one an inflammation of the 
optic nerve, the other a mechanical obstruction to its 
circulation. In either case, to the ophthalmoscope 
the papilla appears engorged, tumefied, nebulous, 
irregular, and with ill-defined edges ; a species of 
cloud covers both the centre and the circumference, 
rendering the whole surface opaque. The arteries are 
diminished in calibre ; the veins appear interrupted at 
various points. In one form of choked disk, probably 
the inflammatory, the capillaries seem increased in 
size ; in the other, effaced. 

According to the celebrated doctrine of von Graefe, 
these appearances are always due to an obstruction 
offered to the venous circulation of the optic nerve, 
from mediate or immediate pressure exercised upon 
the sinus cavernosus. Hence a serous transudation 
from the veins, rendering the papilla swollen and 
oedematous. It has been shown, however, that the 
free inosculation of the ophthalmic vein with the 
angular branch of the facial suffices to avert complete 
venous obstruction, even when the circulation in the 
cavernous sinus has been retarded. Further, a free 
communication has been demonstrated between the 
intervaginal lymphatic space of the optic nerve and 
the subarachnoid space of the brain. It has been shown 
that a rise of intracranial pressure suffices to force 
cerebro-spinal fluid into the intervaginal space of the 



TUMORS OF THE BRAIN. 



91 



nerve, thus causing compression of its central vessels, 
local obstruction, and swelling from transudation, 
apart from venous obstructions. 

Choked disk sometimes appears in cases in which 
the tumor is so small that much increase of intra- 
cranial pressure seems doubtful. It is then more 
probably due to inflammation of the optic nerve, first 
propagated from irritated brain-tissue to the central 
terminations of the nerve — neuritis from diffused 
cerebritis (Mackenzie), or excited by direct pressure 
upon the optic tract. The latter may be effected by 



TABLE IV. 
Cases of Diffused Symptoms Alone. 



Seat. 


45 


.S 

1 
> 

c 
a 

V 
1 


c 
.2 

> 
c 



V 


4 
••3 

1 

V 
V 


> 
a 


II 


-a 
a 
si 

1 

3 
> 

-:^ 

-a 

1^ 


1 
? . 

1 
1.1 


-a 

CD 

II 


1 

'b 



> 


> 

c 

U 


1 

13 

c 

CIS 

c 


> 
s 





Psychic alteration. 


Total. 


Cortex, 57 cases . . 
Lobes, 124 cases . . 
Basal ganglia, 26 cases 
Cerebellum, 90 cases . 


4 
5 
2 
2 


3 
3 

I 
6 


I 

8 

1 


2 


4 

3 


I 
5 




3 
4 


2 


I 
4 
2 

I 


I 
I 


In 7 of these. 

In 22 of these. 

I alone, i besides. 

In 4 of these. 


II = 19 per cent. 
37 =29 per cent. 
6 = 23 per cent. 
17 = 18.5 per cent. 


Total 


13 


13 


10 


2 


7 


6 




7 


2 


8 


2 


35 


71 = 23.8 per cent. 



tumors of the corpora quadrigemina, of the cerebral 
peduncles, or of the interpeduncular space. Table 
II. show^s that the percentage of cases of choked disk, 
in cases of intracranial tumor, is greater in the locality 
of the corpora quadrigemina than in any other. But 
as shown by Table X., it is only present in twenty- 
two per cent, of all cases hitherto observed ; thus is 
less frequent than any of the diffused symptoms 
except convulsion. 



92 TUMORS OF THE BRAIN. 

Choked disk Is found far more frequently (54 
per cent.) in cases in which the tumor involves the 
corpora quadrigemina, than in those in which it 
involves any other part of the brain. The smallest 
percentage is in the class of cases in which the basal 
ganglia are the seat of the tumor. When there is di- 
rect pressure on the optic tract, the papilla sometimes 
atrophies without passing through any stage of choked 
disk. Until atrophy sets in, vision is not necessarily 
impaired. Thus, out of a total of 82 cases of choked 
disk, vision remained intact in ^il^ oi" 45 P^^ cent. 
In a great many cases no ophthalmoscopic examina- 
tion is made, unless vision is impaired, and this ex- 
plains why such examination is lacking to the history 
in 232 out of 485 observations analyzed by Bernhardt 
(47.8 per cent.). In many of these negative cases it 
is very possible that choked disk really existed, so 
that the real proportion of this lesion in brain-tumor 
cannot be considered as known. 

In a certain number of cases cerebral tumor mani- 
fests itself exclusively by one or more of the forego- 
ing "■ diffuse " symptoms. Among Bernhardt's cases 
of tumors of the cortex, centrum ovale, cerebellum, 
and basal ganglia, this limitation may be found seventy- 
one times out of a total of 297 cases, or 23.8 per cent. 

The existence of mental symptoms in a large pro- 
portion of these cases (forty-nine per cent, of them) 
is the circumstance that might, perhaps, most surely 
guide in the diagnosis, otherwise so difficult. 

The proximate consequences of increased intra- 
cranial pressure, and which are the immediate cause 
of the diffused symptoms, have been differently inter- 
preted. It was long maintained that the brain sub- 



TUMORS OF THE BRAIN. 93 

Stance was nearly as incompressible as water. Room, 
therefore, could only be made within the cranium for 
a neoplasm by proportionate expulsion of blood and 
lymph, and by atrophy of the brain-tissues in the 
immediate vicinity of the tumor, Adamkiewicz's ex- 
periments have shown, however, that the nerve-tissue 
surrounding the tumor is compressed, i. e., its solid 
molecules are approximated, and the fluid, normally 
interposed between them, is, to a greater or less ex- 
tent, expelled. For, when a piece of laminaria was 
inserted under the skull of an animal previously 
trepanned for the purpose, and was allowed to swell, 
thus rapidly encroaching upon the intracranial space, 
microscopic examination of the tissue in which the 
foreign body was embedded, revealed the fact that all 
the nerve-elements of this tissue were closely crowded 
together, thus apparently multiplied in a given space. 
The zone adjacent to this was intensely vascularized 
from dilatation and new development of capillaries, 
and, in addition, it was hypertrophied from prolifera- 
tion of connective tissue. 

In the experiment, the swelling of the laminaria was 
much more rapid than is the growth of any tumor, 
and the condensation and nutritive irritation or tissue 
were, therefore, exaggerated. To a greater of less 
extent, however, both these lesions must always be 
produced by the presence of a foreign body within the 
cavity of the cranium. Only when the tumor grows 
very slowly are they absent, or reduced to such a 
minimum as to occasion no symptoms, either diffused 
or focal. 

The occurrence in 23 per cent, of the cases, of dif- 
fused without focal symptoms. Indicates that the 
centres of origin of nerve tracts have remained unaf- 



94 TUMORS OF THE BRAIN. 

fected, though the vomiting and convulsive centres 
and the nervous filaments of the dura mater have 
been irritated ; that lymph has been forced into 
the sheath of the optic nerve, or that a descending 
neuritis has been excited by propagation from the 
zone of cerebri tis surrounding the tumor,' and that 
the delicate psychic mechanisms of the cerebral cor- 
tex have been irreparably jarred and are out of work- 
ing order. 

This immunity of motor, sensory, or special-sense 
nerve-functions, is usually due to the localization of 
the tumor in a '' latent " portion of the brain ; but it is 
also sometimes observed in cases in which the tumor 
occupies a (presumable) focus of nerve-origin. Thus, 
although there can be no doubt that the ultimate 
origin of the motor nerves contained In the pyra- 
midal tracts Is in the central gyri and paracentral 
lobule, tumors seated In these localities have some- 
times been observed entirely unaccompanied by 
motor symptoms, either irritative or paralytic. Two 
such cases are contained among the eleven of the 
table. In one of these there were forty hydatid cysts 
in the brain, a form of neoplasm very frequently 
latent. In the second case, however, there was a 
most extensive sarcoma occupying the lower half of 
the anterior central gyrus, posterior half of third 
frontal gyrus, and under half of insula. 

Two explanations are offered for these cases. 
First, that the elements of the neoplasm have insin- 
uated themselves so gradually between those of the 
nerve-tissue, or have displaced them with so little in- 
jury that the functions of this tissue have not suffered. 
This explanation applies to cases In which, instead of 

' Demonstrated by Adamkiewicz (see ut supra). 



TUMORS OF THE BRAIN. 95 

the cells of a nucleus of origin, the fibres of a nerve- 
tract have been displaced, as in some extraordinary 
cases on record in which a tumor has occupied nearly 
the entire pons, yet has occasioned no motor symp- 
toms. The second explanation applies only to corti- 
cal centres. According to Exner, the different mech- 
anisms of the cortex, though specially concentrated at 
certain localities, exert their influence somewhat be- 
yond these limits, though with constantly diminishing 
intensity and effectiveness. Hence it is occasionally 
possible, though the main centre be destroyed, that 
its action may be supplemented by that of others 
habitually subordinate. 

In more than three fourths of the cases of brain- 
tumor, in addition to the diffused symptoms hitherto 
described, the patient suffers from perversions or 
abolition of one or more cerebral functions other than 
psychic ones. These are known as the focal symp- 
toms. 

Focal Symptoms. — They consist of the perversion 
or abolition of mobility or sensibility in one or more 
cranial nerves or spinal nerve-tracts, or in similar 
alterations of one or more of the special senses. 
Among the latter, however, is to be excepted the im- 
pairment of vision directly traceable to choked disk or 
optic neuritis. An intense interest has recently at- 
tached to these symptoms as a means of unravelling 
the physiological problems of the localization of brain 
functions. For this purpose, however, the study of 
tumors is much less valuable than that of other brain 
lesions, such as, for example, localized softening ; for 
their limits are irregular, and their effects, through 
transmission of pressure, often diffuse themselves in 
structural or functional changes far beyond these vis- 



96 TUMORS OF THE BRAIN, 

ible limits. For clinical purposes, therefore, it is 
necessary to ascertain, first, what symptoms are gener- 
ated by lesions really limited to certain localities ; 
second, to what extent the complication of these by 
others, diffused or symptomatic of different localities, 
may aid us in diagnosing the existence of tumor as 
distinguished from other focal disease. 

Focal symptoms are always unilateral at the begin- 
ning — a most useful criterion in distinguishing tumor 
(as well as other localized lesions) from a diffused dis- 
ease of the brain. The appearance of symptoms on 
the opposite side of the body from that on which 
they first began, indicates an extension of the growth 
across the median line. This, for obvious reasons, 
most frequently occurs at the narrowest regions of 
the encephalon, the pons and (though less frequently) 
the medulla. It is, however, also seen in tumors of 
the corpus callosum, but the second hemiparalysis is 
much slighter than the first. 

Case (Bristowe, Brain^ October, 1884) : Illness twelve weeks. 
Left hemiplegia, gradually extending to right side ; then general 
paralysis, principally on the left side, ten days before death. 
Progressive drowsiness or stupidity, aphasia. Sarcoma occupied 
anterior two-thirds of fornix and corpus collosum, extending into 
the centrum ovale in both hemispheres, but principally in the right. 

In addition to these symptoms involving purely 
cerebral functions, the functions of respiration and 
circulation are sometimes modified from the direct or 
indirect morbid influence exercised upon the medul- 
lary centres. 

Lesio7is of Motility. — These are by far the most 
numerous, the most varied in character and in com- 
bination of all the focal symptoms of brain tumor. 
They belong to three different classes : First, irrita- 



TUMORS OF THE BRAIN. 97 

tive, including tremors, choreiform movements, and 
local spasms ' ; second, ataxic, implying inco-ordina- 
tion among functionally combined movements ; third, 
paralytic, consisting in the partial or complete aboli- 
tion of motive power. 

Irritative Lesio7is of Mobility. — A fine tremor or a 
clonic spasm, incessant or periodically repeated, is 
often seen, either in muscles which have already be- 
come paralyzed, or in those which become paralyzed 
at a later date. 

Case (Berger, Arch, der Heilkunde^ XIX. Jahr.) : Woman, aged 
forty-eight. During a year, about every eight days, an attack of 
clonic spasms in the right arm, then paralysis of the same arm, 
followed by paresis of the buccal branches of the right facial ; 
clonic spasms persist after paralysis sets in ; death a week later. 
Tumor in left anterior central gyrus, compressing the posterior 
and second frontal gyri. 

Case (Berkley, Med. News., 1882) : Patient with spasm of the 
left angle of the mouth for two and a half years. Sudden death 
from cardiac disease. Calcareous nodule three sixteenths of an 
inch in diameter on the right ascending frontal convolution, one 
and a half inch above the fissure of Sylvius ; the locality corre- 
sponds to Ferrier's centre for the zygomatic muscles. 

Tremors and localized spasms are valuable diag- 
nostic symptoms ; for, first, they are more frequent 
with tumors than with other localized brain lesions ; 
second, they are more frequent in the cortex ; and, 
third, they are especially frequent in the motor 
zones. All these circumstances are demonstrated by 
the following tables. The first is compiled from 
Exner's collection of 164 cases, exclusively of cortical 
lesions. 

Tumors of cortex (44 cases) : Spasm, 3 = 6.5 per 
cent.; spasm and paralysis, 14 = 31 percent.; paraly- 

' The general epileptiform convulsion beijig a diffuse symptom. 



98 



TUMORS OF THE BRAIN. 



sis, 14 = 31 per cent.; no motor symptoms, 13 = 29 
per cent. Total spasm, 17=38 per cent. 

Other lesions of cortex (100 cases) : Spasm, i = 0.9 
per cent.; spasm and paralysis, 13 = 11.5 per cent; 
paralysis, 62 = 56 per cent; no motor symptoms, 
36 = 32 per cent. Total spasm, 14 = 12 per cent 

Thus, in more than one third of all cases of brain 
tumor, localized spasms or contractures exist at some 
period of the disease. When present they indicate 
a greater probability of localization in the cortex 
than in any other part of the brain ; and after 
that, in the region of the corpus striatum and 
thalamus opticus. In the table the highest per- 
centage falls to tumors of the peduncle ; but this 
fact is offset by the great rarity of tumors in this 
region. 

TABLE V. 
Proportion of Cases of Spasm with Tumors. 

















^ 




V 








e 


ll 


u «'S 


Seat. 




6 






1 

"5 


8 


2 SiS 

rt 

S &« 







a 

en 






H 


V 


Cortex- 
















Central gyri .... 
Parietal lobe (motor) , 


39 


4 


24 


10 


28 


71 


2 


II 

50 




7 


I 


7 


63 


3 


Total motor zone . . 


4 


31 


II 


35 


70 


5 


Frontal gyri .... 


14 


2 


I 


4 


3 


21 


7 


Other latent parts , . 


13 


I 


2 


2 


3 


23 


8 
















Perot. 


Total cortex . . . 


77 


7 


34 


17 


41 


53 


20 = 25.0 


Centrum ovale .... 


124 


12 


22 


45 


34 


27 


45 = 36.0 


Basal ganglia .... 


41 


9 


10 


14 


19 


46 


8 = 19.0 


Peduncle 


10 


I 


5 


3 


6 


60 


2 = 20.0 


Corp. quad 


13 


I 


3 


2 


4 


30 


7 = 530 


Pons 


56 


3 


7 


38 


ID 


17 


8 = 14.0 


Cerebellum 


165 


20 


12 


26 


32 


19 


107 = 64.5 


Medulla . ..... 


30 


8 


2 


15 


ID 


33 


5 = 16.0 


Total 


516 


... 




... 


156 


30 


202 = 37.5 



It is evident that spasmodic contractions of mus- 
cles may be caused by irritation, either of the nerve- 



TUMORS OF THE BRAIN. 99 

elements of a motor-centre, or of the fibres of a 
motor-tract descending from it, but that the first con- 
dition is more favorable. Tumors of the pons and 
medulla are rarely accompanied by spasm ; it seems 
that the liability to irritation increases higher up in 
the tract, and also when the latter is more incom- 
pletely invaded. 

Paralyses of Motility, — These are especially char- 
acterized, as a rule, by their gradual development, a 
circumstance which is most useful in distinguishing 
brain tumors from hemorrhage. It does not, how- 
ever, serve to differentiate tumors from softening ; for 
in the latter the paralysis is also gradually developed. 

To a certain extent the paralyses of tumors share 
the peculiarities of those caused by other lesions of 
the same locality. As already stated, however, in the 
case of tumors, the paralyses are rarely purely typical 
throughout the whole course of the disease, because 
they constantly tend to encroach upon other regions 
than that in which they originated, and because their 
influence, by transmitted pressure and nutritive irrita- 
tion, is apt at all times to diffuse itself considerably 
beyond the region which they visibly occupy. A 
paralysis which may seem at a given stage to be en- 
tirely atypical, may, however, exhibit in the history of 
its development peculiarities which point out the true 
nature of the disease. The paralysis has been pre- 
ceded by a slowly progressing paresis, or by tremor or 
spasm in the affected muscles, or has existed in one 
set of muscles, or in one limb, or in one or more 
cranial nerves ; or there has been a combination of 
paralyses of such nerves with others of the extremi- 
ties before the disease reached its complete evolution. 
Or, further, the very first appearance of a paralysis may 



lOO TUMORS OF THE BRAIN. 

have been preceded by one or more diffused symptoms ; 
or it may have been ushered in by an epileptiform 
convulsion or an apoplectic attack, remarkable for its 
brevity and incompleteness. Or a paralysis may de- 
clare itself at once, in a fully developed form, but iso- 
lated, as in one facial nerve, and after prolonged 
headache, attacks of vomiting, and change of mind or 
character of the patient. The typical characteristics 
of the paralyses, according to locality, are as follows : 
Cortex. — The paralysis, at the outset at least, is 
"■ dissociated," monoplegic. One arm or one side of 
the face is affected, or the two together are affected 
on the same side. It is extremely rare that paralysis 
begins in the leg ; but this extremity often becomes 
involved later, and then the patient suffers from a 
complete hemiplegia, difficult to distinguish at first 
from the common hemiplegia due to hemorrhage into 
the internal capsule. It is very rare, however, that 
the paralyzed limbs become rigid. It is with tumors 
in this region that clonic spasms are most frequent 
either before or during the paralysis. Symptoms of 
tumors of different regions of the cortex follow, ap- 
proximately, the rules which have been laid down for 
other lesions, according as they occupy the " latent " 
or the motor zones. The latent regions are those 
parts of the brain in which, with rare exceptions, 
lesions produce no motor symptoms. The motor 
zones are those whose lesions are always followed by 
spasm or paralysis, except in very few cases, in which 
the absence of symptoms is explained by the ex- 
tremely slow growth of the tumor which allows nerve- 
tissue to accommodate itself to increased pressure. 
When an *' absolute field" exists it will be found that 
in all cases in which motor symptoms are absent this 



TUMORS OF THE BRAIN. lOI 

field Is entirely free from lesion. In the regions ad- 
jacent to these, lesions sometimes do and sometimes 
do not produce symptoms. This fact, as already 
stated, has been explained in two ways — by the 
theory of transmitted pressure, and by the theory of 
a " relative field," which contains motor mechanisms 
of less degree of intensity and concentration than 
those belonging to the '' absolute field." The abso- 
lute motor zones are : 

First, for the upper extremity, the anterior central 
convolutions, especially the lower two-thirds, the up- 
per half of the posterior central convolution, the para- 
central lobule, and, in the left hemisphere, the greater 
part of the superior parietal lobe, and possibly a few 
points on the occipital. 

Second, for the lower extremity, it is the upper 
third of both central convolutions and the paracentral 
lobule, and in the left hemisphere again the greater 
part of the superior parietal lobe. This " absolute 
field" is, according to Exner, surrounded by a relative 
field which occupies the posterior half of the superior 
frontal gyrus, almost the entire convex surface of the 
other two frontal gyri, both parietal lobes, and the 
upper part of the occipital lobe. This field belongs 
to both extremities. 

Third, there is no absolute field for either facial 
muscles or tongue, the mechanisms for both seeming 
to be diffused over the greatest part of the hem- 
ispheres. But the seat of greatest concentration for 
the facial nerve exists in the lower half of the anterior 
central gyrus, and the lower third of the posterior 
central, while a relative field extends over the poste- 
rior half of both lower frontal gyri and the anterior 
part of the supramarginal gyrus. The principal 



I02 TUMORS OF THE BRAIN. 

centre for the hypoglossal nerve is the lower part of 
the anterior central gyrus and adjacent part of the 
middle and inferior frontal gyri. 

Fourth, no definite cortical field has been outlined 
for either the motor oculi nerve or the trigeminus. In 
regard to the first, however, it seems certain that all 
the branches of both nerves are influenced by the 
centres of a single hemisphere. 

The zone for common sensibility coincides with 
the motor zone as above defined. 

Fifth, the zones latent in regard to motor or 
sensory symptoms include all the frontal lobes, the 
temporo-sphenoidal lobes, the parietal lobe of the 
right hemisphere, and the occipital lobes. Lesions of 
these lobes may remain absolutely latent, and did so 
in 13 of Exner's 44 cases of tumors; that is, in 29 
per cent. But even when unattended by paralysis or 
spasm lesions of these latent zones are liable to be 
followed by such disorders of speech, of vision, or of 
hearing as lead to the localization, within their boun- 
daries, of the centres for these important functions.^ 
In Table V. it will be seen that there were 9 cases of 
paralysis, with or without spasm, occasioned by 
tumors in the non-motor regions ; the percentage of 
paralysis to whole number of such tumors being 'i^'j. 
Out of the whole number of cases of paralysis from 
']'] tumors of the cortex (51 cases), the percentage 
belonging to tumors of non-motor regions was 17.5 
per cent; that of those belonging to motor regions 
(42 cases) was 54 per cent, of the whole, and 84 per 

^ The wide diffusion of the mechanisms for the motor-oculi nerve and the 
facial, which render their paralyses of little .value in regional diagnosis, is 
probably correlated to the complex relations of these two nerves to the mech- 
anisms of psychic existence, and their functions in the innumerable shades of 
facial expression. 



TUMORS OF THE BRAIN. 



103 



cent, of the tumors of that region ; while, finally, 
the probability that a tumor situated in the cortex 
would occasion some form or degree of paralysis is 
indicated by the relation of 51 to "]"], or 66 per cent. 

Centrttm Ovale. — A much larger percentage of tu- 
mors remain latent in this region than in the cortex, 
as, for example, 36 per cent, instead of 25 per cent, 
(see Table V.). The absence of symptoms is to be 
expected when the tumor neither occupies nor affects 
bundles of fibres coming from the motor regions of 
the cortex. In the following table, Ladame's and 
Bernhardt's cases are combined, and show to what 
extent tumors situated in non-motor regions may yet 
inhibit the mechanisms of the motor regions : 



TABLE VI. 
Paralysis with Tumors of Centrum Ovale. 



Motor Regions. 


Non-Motor Regions, 


Seat. 


Paralysis. 


No. Pa- 
ralysis. 


Seat. 


Paralysis. 


No. Pa- 
ralysis. 


Pars centralis ante- 
rior and posterior 
(Petres) . . . 


61 


16 

i 


1 
Pars frontalis . . 
Pars occipitalis . 
Temporal lobe . 
Otlier parts . . 

Total. . . . 


37 
10 
2 


37 

23 

3 

7 


Total .... 


61 


.. i 


49 


70 



The paralyses which are associated with tumors of 
this region present nearly the same characteristics as 
do those associated with tumors of the cortex if they 
are near the surface ; that is, they are liable to be 
monoplegic ; but they resemble those of tumors of 
the internal capsule if they approach the basal gan- 
glion, in which case they may become completely 
hemiphlegic, and may be followed by rigidity. Usu- 
ally a long period of paresis precedes that of complete 
paralysis. 



104 TUMORS OF THE BRAIN. 

The percentage of cases of paralysis in tumors of 
the centrum ovale, whether calculated from the smaller 
number of cases in Table VI., or from the larger 
number in Table V., is about the same, viz. : 54 in 
the first case, 56 in the second. 

Basal Ganglia, — Tumors of the corpora striata, op- 
tic thalami, and lenticular nuclei occasion hemiple- 
gias, which often differ from those of hemorrhage in 
the same region, exclusively by their gradual rate of 
development. The paralysis is, however, sometimes 
monoplegic ; thus, out of 41 cases it was confined to 
the facial nerve four times, to the arm once, to the 
arm and facial once, and to the leg once. It is ex- 
tremely remarkable that large tumors may exist in this 
region without causing any symptoms whatever. This 
is the rule for tumors limited to the thalamus or to 
the lenticular nucleus. Acute lesions, such as hemor- 
rhage in the latter ganglion, cause temporary hemiple- 
gic symptoms ; but these subside, probably because 
the function of the destroyed tissue is supplemented 
by that of other motor centres. But such temporary 
paralyses are not seen with chronic lesions, as, for 
example, tumors, unless they are complicated by an 
accidental hemorrhage. 

But tumors limited to the corpus striatum will cer- 
tainly cause paralysis if they involve the anterior two- 
thirds traversed by the motor tract of the internal 
capsule. It is injury to this tract which determines 
the phenomenon of '' late rigidity " ; a phenomenon 
depending on the descending degeneration which 
reaches the spinal cord, and which, though so com- 
monly seen after cerebral hemorrhage, is not peculiar 
to that lesion, but only to the locality which it most 
frequently occupies. 



TUMORS OF THE BRAIN. I05 

If a tumor involve the posterior third of the inter- 
nal capsule, whose fibres pass between the corpus stri- 
atum and the thalamus, it tends to destroy the sensory- 
fibres which pass in this locality (Charcot, Veysiere), 
and to cause a hemianaesthesia in addition to the motor 
paralysis. This complication is, therefore of great 
use in establishing the diagnosis of tumors of this 
region, which, from their encroaching tendencies, are 
so liable to involve all parts of the internal capsule. 
It is possible that a transmitted irritation to sensory 
fibres has something to do with the high percentage 
of spasms observed in tumors of the basal ganglia 
(46 per cent, see Table V.). There were 24 cases 
of paralysis, with and without spasm, which is 58 
per cent, of the whole number. 

Peduncle. — As might be expected, tumors of this 
region cause hemiplegic paralysis in almost all cases 
(80 per cent.). Together with the extremities, the 
facial nerve and also the hypoglossus are usually in- 
volved. The most characteristic circumstance, how- 
ever, is the paralysis of the motor-oculi nerve by 
direct pressure upon its trunk as it emerges in the 
interpeduncular space. The paralysis is on the same 
side as the tumor ; that is, on the side opposite to the 
hemiplegia. The paralysis is usually total, in which 
case there will be unilateral dilatation of the pupil, 
ptosis from paralysis of the levator palpebrae muscle, 
and divergent strabismus from paralysis of the inter- 
nal rectus. In other cases, one or more of these 
symptoms may exist alone. As the tumor grows 
larger, it sometimes crosses the interpeduncular space, 
and compresses the nerve on the opposite side. This 
important symptom existed in seven out of the ten 
cases of Ladame and Bernhardt. It is not, however, 



Io6 TUMORS OF THE BRAIN. 

absolutely pathognomonic of lesions of the peduncle ; 
for It results, with exactly the same forms, from every 
tumor of the interpeduncular space ; thus, from those 
springing from the base of the cranium. 

Corpora QuadrigeTnina. — Tumors of these bodies 
lie outside of the direct cerebro-splnal motor tracts, and 
thus produce much less definite motor symptoms. 
Some degree of paralysis existed in 5 out of 13 cases; 
in I, paresis of the arm and facial nerve; in 2, a uni- 
lateral facial paresis ; in i, paresis of one leg; and in 
I, paresis of one half of the body. 

On the other hand the motor-oculi nerve seems to 
be paralyzed as often as In the case of tumors of the 
peduncles ; a fact which might be expected from the 
proximity of the corpora quadrlgemina to the nuclei 
of the nerves which lie Immediately below them. In 
14 cases divergent strabismus existed In 8 (five cases 
of Bernhardt, three related by Nothnagel). In one 
other case the abducens was paralyzed, so that Inter- 
nal strabismus existed (Gowers, Lancet, 1879). 

CerebellM7n. — Absence of true motor paralysis, taken 
together with impairment of the power of equilibra- 
tion, is highly characteristic of tumors of the cere- 
bellum. Out of a total of 165 cases, only 2)^ showed 
any kind of paralysis (23 per cent). This is almost 
the proportion In which the symptom Is absent in 
tumors of the cerebral cortex. Excluding the cere- 
bellum and corpora quadrlgemina, the probabilities of 
paralysis with brain tumor are expressed by the per- 
centage 89, while for the cerebellum and corpora 
quadrlgemina alone the percentage Is only 24. 

Tumors of either lateral lobe of the cerebellum 
cause of themselves no motor symptoms, even ataxic, 
and may be completely latent. Out of the 2)"^ cases 



TUMORS OF THE BRAIN. ID/ 

of paralysis the tumor occupied the middle lobe of 
the cerebellum in 4 ; in 5, one of the peduncles; in 
15, though mainly situated in a lateral lobe, it ex- 
tended into the middle lobe, or else compressed the 
pons or medulla. 

The facial nerve may be affected either by an Iso- 
lated, by an alternating, or by a hemiplegic paraly- 
sis, in the rare cases in which hemiplegia occurs. 
The lesion is never really of cerebellar origin, but 
always secondary to encroachment upon the pons or 
medulla. 

Pons Varolii. — In this locality tumors produce the 
most extensive and also the most complex combina- 
tions of paralyses. They are occasionally paraple- 
gic, and not infrequently they become, little by little, 
generalized throughout the four limbs. This creep- 
ing generalization is highly characteristic of tumors 
of the pons. On the other hand, only cranial nerves 
may be affected. 

Case (Wernicke, Archiv. f. Fsychiat., Bd. vii.) : Patient aged 
fifty-eight years. In July, headache, diplopia, difficulty in open- 
ing and shutting mouth. By end of iVugust, paralysis of left 
facial nerve, including upper branches ; rigidity of left masseter ; 
eyes persistently deviated toward the right ; diminished sensi- 
bility of face and head on the right side ; that is, on the side 
opposite to the facial paralysis. Death occurred in October with- 
out further motor affection. Section discovered a tumor on the 
floor of the fourth ventricle, on the left side of the middle line. 
Associate nucleus of facial and abducens completely destroyed ; 
left facial nerve nucleus, as also part of the fibres of the right 
trigeminus destroyed. 

After the frequent generalization of the paralysis, 
the remarkable symptoms of pontine tumors are : i. 
The coexistence of hemiplegic paralysis of the ex- 
tremities with paralysis of one or more cranial nerves 



I08 TUMORS OF THE BRAIN. 

on the opposite side of the body ; alternate paralyses. 
2. The occurrence of ?i persistent conjugate deviation 
of the eyes, thus distinguished from the same symp- 
tom in lesions of the hemispheres, where it is always 
transitory. To these positive symptoms may be add- 
ed an important negative characteristic, namely, the 
nearly complete absence of local irritative symptoms, 
and, to an even more marked degree, of general con- 
vulsions. The alternate paralyses are produced by 
tumors in the lower part of the pons, which injure 
the nerve-nucleus or compress the nerve-trunk on the 
side on which they are situated, and injure the gen- 
eral motor tracts of the limbs previous to their de- 
cussation, so that the resultant hemiplegia follows 
the usual law for cerebral paralysis, and appears on 
the side of the body opposite to the lesion. When 
the tumor occupies the upper segment of the pons 
anterior to the cerebral peduncles, the facial paralysis 
will be on the same side as the limb, since it depends, 
not on a lesion of the nucleus, or nerve-trunk, but on 
one involving the central fibres after their decussation. 

In the most typical cases all the branches of the 
facial are paralyzed, including those innervating the 
orbicularis palpebrse. The eye cannot be closed, and 
the patient presents the appearance of Bell's paraly- 
sis. The electric excitability of the nerve may then 
be diminished. However, neither of these last con- 
ditions is invariable, even when the paralysis is alter- 
nate. 

Double facial paralysis is extremely rare. It is le- 
sions of the pons which have furnished the explana- 
tion of the remarkable phenomenon — conjugate de- 
viation of the eyes — which for a long time puzzled 
pathologists. This deviation implies paralysis of the 



I 



TUMORS OF THE BRAIN. IO9 

abducens nerve of one side, supplying the external 
rectus, and coincident paralysis of a branch of the 
motor-oculi nerve supplying the internal rectus on the 
opposite side. The apparent remoteness from each 
other of the nuclei of origin of these two nerves ren- 
dered this phenomenon extremely difficult to under- 
stand, until the discovery was made, in the pons, of a 
common nucleus, which unites fibres of the abducens 
with fibres from the lower nucleus of the motor-oculi 
on the opposite side. Destructive lesions of this 
associate nucleus are followed by a permanent conju- 
gate deviation, as in the case (Wernicke) above 
quoted. It becomes evident that the transitory devi- 
ations of the eye, frequently seen immediately after 
an attack of hemorrhage into any part of the brain, are 
due to a remote shock propagated to this same nucleus. 

The abducens nerve is not infrequently paralyzed 
alone, causing a converging strabismus of the affected 
eye. 

Isolated paralysis of the motor-oculi nerve is much 
more rare, and is seen only when the tumor or its in- 
fluence extends above the pons into the cerebral 
peduncles, or above them to the nerve nuclei. Ptosis, 
from isolated paralysis of the levator palpebral 
branch, has sometimes been observed alone, and, so 
far, in cases of tumors, but not in those of any other 
lesion. This symptom would, therefore, be useful in 
differential diagnosis. 

Paralysis of the hypoglossus is not rare. It is indi- 
cated by an impairment of the voluntary movements 
of the tongue and by disturbance of speech, anarthria. 
Tl]is paralysis alternates with that of the extremities. 
It is distinguished from progressive bulbar paralysis 
by absence of atrophy of the tongue. 



no 



TUMORS OF THE BRAIN. 



The motor branch of the trigeminus is sometimes 
paralyzed, more often irritated, causing, in the latter 
case, spasmodic trismus, or clonic convulsions of the 
muscles of mastication. 

Difficult deglutition is also sometimes present, but 
does not seem to be attributable to paralysis of the 
pharynx muscles, but rather to be a secondary conse- 
quence of paralysis of the tongue and of certain mus- 
cles innervated by the facial nerve, the styloglossus, 
digastricus, and stylohyoideus (Nothnagel). 

The following table exhibits the various combina- 
tions of paralysis which have been observed with tu- 
mors of the pons : 

TABLE VII. 
Motor Paralyses with Tumors of Pons (56 Cases). 



Cranial nerves alone. 


Limbs alone. 


Combination of limbs 
and cranial nerves. 


No motor 
symptoms. 


3d nerve 2 

7th nerve 3 

3d and 6th nerves . . 2 
6th and 7th nerves . 3 
7th and 12th nerves . i 
3d, 7th, and 12th nerves i 
3d, 5th, 7th and 12th 
nerves i 


Hemiplegia ... 7 
Paraplegia .... 3 
Four extremities . 2 
Arm alone . . . . 1 


On sa7ne side. 
Hemiplegia and 7th 
nerve 4 

A Iternate paralysis. 
Hemiplegia and— 
3d nerve .... 2 
6th nerve .... 3 
7lh nerve .... 4 
3d and 6th nerves . i 
3d and 7th nerves . 3 
6th and 7th nerves . 5 
3d, 6th, and 7th 

nerves . . . . i 
3d, 5th, 7th, and 12th 

nerves . . . . i 
3d, 6th, 7th, and 12th 

nerves . . . . i 


4 


Total .... 13 


Total .... 13 


Total .... 25 


* 



The number of cases in which the cranial nerves or 
those of the limbs were paralyzed independently of 
each other is, in this collection of cases, exactly equal. 
The number of cases of combined paralyses is just 
double that of either of the classes of isolated paraly- 
ses. Among the cranial nerves, the liability of the 



TUMORS OF THE BRAIN. 



Ill 



facial is evidently the greatest. It was affected, alone 
or in combination, twenty-four times ; the abducens 
sixteen times. 

Medulla. — In this region the liability to paralysis 
again diminishes. Tumors of the medulla are not 
infrequently confined to the floor of the fourth ven- 
tricle, so that the motor tracts and nuclei are both left 
uninjured. In this case the patient escapes all paraly- 
sis ; indeed, he often remains with singularly few 
symptoms for the subject of an organic disease seated 
so near to vital nerve-centres. Out of 30 cases, 12, 
or nearly half, remained free from motor symptoms. 
In one case, so far unique (Erichsen, Peter sb, Med, 
Zeitschr., 1870), a bilateral paralysis of the vocal 
cords was noted, due to lesion of the accessory nerve. 

TABLE VIII. / 

Motor Paralyses with Tumors of Medulla (30 Cases). 



Cranial nerves alone. 


Extremities. 


Combination. 


Negative. 


3d nerve 2 

7th nerve 2 

3d and 7th nerves . . i 
'7th and iTth nerves . i 
5th, 6th, and 7th 
nerves i 


Hemiplegia . . . i 
3 extremities . . . i 
Paraplegia .... 2 
General 2 


Hemiplegia and 6th 
nerve i 

Same side. 
Hemiplegia and— 

6th nerve (alternat- 
ing) I 

3d, 6th, and 7th 
nerves . . . . i 

3d, 7th, and 12th 
nerves . . . . i 

7th and associated 
3d and 6th nerves i 


12 


Total 7 


Total 6 


Total 5 


12 



Ataxia. — This third form of motor lesion is princi- 
pally seen with tumors of the cerebellum and corpora 
quadrigemina ; the latter, possibly from the connec- 
tion of these bodies with the cerebellum through the 
superior cerebellar peduncles. In the pons and me- 
dulla, the advent of paralysis is often preceded for 
some time by a staggering or reeling gate 'Mike a 



112 TUMORS OF THE BRAIN. 

drunkard's." This same symptom is very conspicuous 
in tumors of the cerebellum^ and, when associated 
with the negative symptoms of absence of motor or 
sensory paralysis, points very strongly to tumors of 
this region. For the development of the symptom, 
however, it is essential that the middle lobe be in- 
volved or indirectly affected. Tumors limited to a 
lateral lobe are characteristically latent. 

Forced movements or inclinations of the body or 
head to one side or the other are sometimes associated 
with tumor in a lateral peduncle on the corresponding 
side. A tendency to fall forward or backward has 
been associated with the situation of the tumor in the 
anterior or posterior extremity of the upper or lower 
processus vermiformis (middle lobe). 

Lesions of Sensibility. — With the exception of 
headache, already described as a diffuse symptom, 
alterations of sensibility are very much less prominent 
in the symptomatology of tumors than alterations of 
motility. 

It is evident from this table that, in the cortex, the 
seat of sensibility coincides with the seat of motility. 
Pain or anaesthesia rarely exists without paralysis, or 
except in connection with tumors situated in the motor 
zones. The liability to pain, other than headache, 
with tumors of the centrum ovale, is very slight (fivQ 
cases out of one hundred and twenty-four).' 

It has already been pointed out that tumors of the 
basal ganglia will cause hemianaesthesia in paralyzed 
limbs, provided they involve the bundle of fibres 
which pass in the posterior third of the internal cap- 

* The percentage of headache, however, was sixty-six, the highest after the 
cerebellum and rare cases of corpora quadrigemina. The liability to head- 
ache, from distension of the dura mater, is constantly seen to bear no propor- 
tion to perversions of sensibility due to lesion of sensory tracts or centres. 



TUMORS OF THE BRAIN. 



113 



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sule, otherwise they will not be attended by lesions of 
sensibility. The table, therefore, expresses the proba- 
bilities of this precise situation, in giving the propor- 



114 TUMORS OF THE BRAIN. 

tion of cases of pain or anaesthesia as eight out of 
thirty-nine, or twenty per cent. 

The highest percentage is with tumors of the pons, 
and the next highest, if the few cases of tumors of 
the peduncles of the cerebrum be excluded, is with 
those of the medulla. In these places occur pain and 
anaesthesia in the facial range of the trigeminus, 
symptoms almost peculiar to such tumors. When 
similar symptoms are excited by tumors of the cere- 
bellum, it is only because the pons or medulla has 
been compressed. Trigeminal neuralgia or anesthesia 
is, like cramp or paralysis of the masticatory muscles, 
a most important symptom for helping to localize a 
tumor in the posterior cranial fossa. It is noticeable 
(see table,) that trigeminal anaesthesia has hitherto 
been observed on the side opposite to the paralysis, 
while anaesthesia of the extremities has nearly always 
existed on the same side. 

The cerebellum and corpora quadrigemina show 
the same minimum liability to lesions of sensibility 
as they do to motor paralysis. Their percentage, 
almost alike for the two cases, is however, not lower 
than that of the centrum ovale. 

Comparison of the latter with the cortex on the 
one hand, and with the peduncle, pons, and me- 
dulla on the other, seems to indicate that sensation 
is affected either by lesion of terminal nerve-cells (as 
in the cortex), or of very concentrated bundles of 
nerve fibres. When these are widely disseminated, 
as in the centrum ovale, so that a few can only be in- 
volved in the lesion, motor power may, nevertheless, 
suffer extremely, while sensibility remains intact. 

Lesions of the Special Senses. — Vision. — Dis- 
turbances of vision are extremely frequent as symp- 



TUMORS OF THE BRAIN. 1 1 5' 

toms of brain tumor, and are of three kinds : First, 
atrophy of the optic papilla as a consequence of 
choked disk, and therefore as a remote consequence 
of increased intracranial pressure ; second, deviations 
of the eyeball or eyelids from isolated or combined 
paralyses of the nerves supplying the ocular muscles, 
the third, sixth, and seventh ; third, finally, amblyo- 
pia or amaurosis, resulting from direct affection of the 
optic nerve in its course through the cranium, or at 
its cerebral centres, the mode of development being 
therefore almost precisely analogous to that of pa- 
ralysis of any other nervous tract by direct compres- 
sion. The first two kinds of ocular defect have been 
sufficiently described ; the third comprises two differ- 
ent kinds of lesions, those affecting (by compression) 
the optic tract or chiasma, and those which affect the 
optic stations of the posterior extremity of the thala- 
mi or at the corpora quadrigemina, or else at the final 
visual centres of the cortex. 

The optic nerve or chiasma is liable to compression 
from tumors arising from the base of the cranium, or 
from the hypophysis, and also from tumors of the 
peduncle ; an acute descending optic neuritis, with 
atrophy of the papilla, is usually excited. When one 
tract or one side of the chiasma is compressed, hemi- 
opia results, a phenomenon dependent on the semi- 
decussation of nerve fibres which takes place in the 
human chiasma. Thus pressure on the right side 
beyond the chiasma, of such a nature as to injure the 
fibres of one tract, will abolish vision in the right 
half of both eyes. A tumor in front of the chiasma 
may cause temporal hemiopia of both eyes, since it 
injures fibres coming from the nasal half of both 



Il6 TUMORS OF THE BRAIN. 

eyes. There is no way in which a double nasal 
hemiopia can be produced by tumors at the base of 
the brain. 

Tumors of the thalamus might be expected to 
affect the sight from lesion of the corpus genicula- 
tum, with its branch to the optic tract. As a matter 
of fact, however, blindness is not very common from 
tumors of this locality — only five cases out of twenty- 
six (nineteen per cent.). Tumors of the corpora 
quadrigemina, however, have an immensely large 
proportion of cases. Out of eleven, nine showed 
either amblyopia or amaurosis, five with and four 
without choked disk (eighty-one per cent). 

Visual defects from lesions of the cortex are ex- 
tremely interesting in connection with two physio- 
logical problems, viz., the question of a second 
decussation of optic-nerve fibres in the cerebrum 
(Charcot), and that of the localization of the mental 
centre of vision. This centre was placed by Ferrier 
at the angular gyrus, as an inference from direct 
experiment upon the brain of monkeys. But Ex- 
ner, on the authority of four cases of lesion reaching 
to the cortex, of which two were tumors, places the 
visual centre in the first and second occipital gyri — 
the cuneus and adjacent part of the lobulus quadratus. 

Case (Gowers, Lancet^ 1879) : Visual hallucinations of a peculiar 
nature, associated with some degree of amblyopia, affecting both 
eyes, but more markedly the left. Tumor occupying first and 
second occipital gyri, posterior half of superior and inferior parie- 
tal lobes, the cuneus, and a part of the lobulus quadratus. 

Case (Jastrowitz, Centralbl. filr prakt. Attgenhcilkunde, vol. i., 
1877) : Paralysis of both right extremities and facialis; aphasia, 
with agraphia ; hemianopsia dextra. Tumor of the left occipital 
lobe, principally in the occipital gyri and the prsecuneus. 

Case (Pooley, Arch. f. Augen. tind Ohrenheilk.^ Bd. vi.) : 



TUMORS OF THE BRAIN. II7 

Together with various characteristic symptoms of brain tumor in 
a syphilitic man, extensive binocular hemianopsia. Tumor in 
posterior lobe of left hemisphere, surrounded by extensive zone 
of softening. Left thalamus completely softened. 

A tumor of one hemisphere may thus cause double 
hemiopia, a single or double amblyopia or amaurosis, 
and visual hallucinations of various kinds. The 
double hemiopia from cerebral lesion, has been in- 
terpreted as a proof that, arrived at the cerebral hem- 
ispheres, optic fibres which had decussated in the 
chiasma, recrossed to the opposite hemisphere, thus 
finally arriving at the same side as the retina, from 
which they started. Hemiopia is habitually unaccom- 
panied by choked disk. It is indeed rare as a symp- 
tom of tumor, and has been principally studied In 
connection with other lesions.' 

Six cases of amblyopia and amaurosis have been 
observed with cortical tumors, unaccompanied by 
choked disk. These are all to be attributed to a le- 
sion of the visual centre ; and, when located in the 
frontal lobe, the lesion must be regarded as indirect. 
The amaurosis or hemiopia, with tumors of the cen- 
trum ovale (39 cases, or 31 per cent.), probably always 
implies a transmitted lesion of the cortical visual cen- 
tre. Of the two cases of hemiopia, referred to in 
Table X., one is used by Exner and Nothnagel as 
documentary evidence in support of the theory of a 
visual centre In the cortex of the occipital lobe, but it 
is placed by Bernhardt among the tumors of the 
lobes. The total percentage of blindness is higher 
with tumors of the cerebellum than with those of any 
other locality, except the corpora quadrlgemina. Out 
of ninety-one cases there are forty-one with some de- 

^ See Seguin's papers on Hemiopia in Journal Mental and Nervous Disease. 



Ii8 



TUMORS OF THE BRAIN. 



gree of blindness (45 per cent). Of these, twenty- 
three, or nearly half, are without choked disk ; the 
blindness being therefore due to the direct action of 
the tumor upon some visual centre. It seems most 
probable that the centre then affected is that of the cor- 
pora quadrigemina ; the influence being transmitted 
through the superior cerebellar peduncles. The high 
percentage of blindness in the two localities so espe- 
cially liable would be shown, therefore, to have the 
same significance. Tumors of the pons and medulla 
also determine amaurosis otherwise than by choked 
disk, through direct upward pressure upon the corpora 
quadrigemina. The direction of the transmission is 
the same as for the upper (unassociated) nucleus of 
the motor-oculi nerve, which lies just below the cor- 
pora quadrigemina. Out of a total of fifty-one 
cases for medulla and pons together, there are four- 
teen cases of amblyopia or amaurosis, or twenty-seven 
per cent. 







TABLE X.- 


—Lesions of 


Vision (in 369 Cases). 












WiTH Choked Disk. 


Without Choked Disk. 


Negative. 


Seat. 


wi 


'1 

1 

X 


S 


1 

a 
< 


G 


V 


& 

a 


"I 

3 

a 
< 


en 

2 

3 

a 
< 




e2 


4 

••5 

•0 





Central gyri . . . 
Parietal .... 

Frontal 

Occipital .... 
Temporal .... 
Entire cortex . . 

Centrum ovale . . 
Basal ganglia . . 
Cerebral peduncle 
Pons 


a 


56 
124 

26 
10 

30 
21 

91 
II 




4 

I 
I 

4 
2 


I 
I 

I 
3 
II 

3 

14 
3 


5-0 
12.0 

13.0 
45-0 


J I occipital. 
^ j I frontal. 


3 

I 

4 

9 

4 
2 

6 

I 
9 
3 


2 

2 

13 

I 

3 
14 

I 


10.5 
19.0 
19.0 

20.0 
36.0 


16.0 
31-5 
19.0 

33-0 
19.0 
450 
81.0 


3 

4 
12 

2 

3 
2 

II 

I 


20 

12 
8 

3 

43 

70 
18 
7 
18 


Medulla .... 
Cerebellum . . . 
Corpora quadrigemin 


15 

39 

I 


Total .... 


369 




12 


37 


... 




42 


36 






38 


254 



Total lesions of vision = 118 in 362 cases = 31 per cent. 



TUMORS OF THE BRAIN. II9 

To judge from this table we should infer that the 
chances of amaurosis in brain tumor were exactly 
equal, whether choked disk existed or not ; but that 
the chances of amblyopia were three times as great 
without the choked disk as with it. This probably 
means that if choked disk occur, the impairment of 
vision which may have been initiated independently of 
it, by the direct influence of the tumor, will rapidly 
increase to complete blindness ; whereas, without this 
local complication, the visual defect may for a much 
longer time, or even altogether, remain partial and in- 
complete. 

Hearing, Taste, and SmelL — All these special 
senses together are less frequently affected than is 
vision alone. Out of a total of three hundred and 
sixty-nine cases of brain tumor, lesions of vision ex- 
isted in one hundred and eighteen, or thirty-two per 
cent. But in a total of five hundred and fifty-four 
cases (which include Ladame's), hearing, taste, and 
smell are altogether only affected in sixty-seven, or 
twelve per cent. In forty-six out of these sixty-seven 
cases the patient suffered from either tinnitus or deaf- 
ness, the latter rarely complete. In twenty-six out of 
the forty-six, thus in more than half, fifty-six per cent., 
the tumor was situated in the cerebellum. This fact 
tends to confirm, if need be, the recent anatomical 
demonstration, which traces the central fibres of the 
acoustic nerve to the cerebellum. By far the highest 
percentage of disturbance of hearing is exhibited by 
tumors of the corpora quadrigemina. It is singular 
that reports of tumors of the frontal lobes so rarely 
mention symptoms indicating lesion of the olfactory 
tracts. It would seem that an indirect influence or 
diffused pressure is insufficient to pervert the sense of 



I20 



TUMORS OF THE BRAIN. 



smell ; that is only affected by actual disorganization 
of the tracts. In a few cases, anosmia, associated 
with frontal headache, psychic disturbance, and ab- 
sence of motor or sensory paralysis, has been a valua- 
ble symptom which correctly pointed to tumor in the 
frontal lobes. But anosmia has also been observed 
with a tumor of the supramarginal convolution. The 
sense of taste, though controlled by two medullary 
nerves, usually escapes injury, even with tumors of 
the medulla, 

TABLE XI. 
Lesions of Special Senses (561 Cases — 369 for Vision). 



Seat of tumor. 



Cortex (59 cases) . . . . 
Cerebrum ovale (192 cases) 

Basal ganglia (41 cases) . . 

Peduncle (3 cases) . , 

Corp. quad. (13 cases) . . . 

Cerebellum (167 cases) . . 

Pons (56 cases) . . . . 

Medulla (30 cases) . . . . 

Total 



i-S 
4.0 
4.0 

30.0 
150 

6.0 



8.0 



eS-3 

2S 



I.O 

16.0 
10. o 



3-5 



[6.0 
20.5 



Disturbances of Language, — These symptoms, 
formerly confounded either with symptoms of mental 
alienation, or else with difficult articulation caused by 
tongue paralysis, have, during the last two decades, 
acquired an extreme interest and importance. The 
discovery that a patient may retain other mental con- 
ceptions, yet lose that of spoken or written speech ; 
furthermore, that the generic defect may be again re- 
solved into several modes, namely, aphasia proper, 
agraphia, alexia, and simple '' word-blindness " ; this 
discovery has immensely widened the horizon of ideas 
in regard to the physiology and pathology of the 



TUMORS OF THE BRAIN. 121 

brain, and has enriched the symptomatology of all 
brain diseases, including tumors. 

According to the most recent classifications, cases 
of aphasia must be divided into two classes : sensory 
aphasia, or aphasia of reception ; and motor aphasia, 
or aphasia of transmission. In the first class, the 
patient fails to understand the significance of language, 
which he hears merely as an unintelligible sound. In 
the second, if uncomplicated, he understands entirely 
what is said, but is unable to express himself in words. 
The lesion of sensory aphasia is located in the pos- 
terior part of the first temporal convolution of the 
left hemisphere ; the lesion of motor aphasia is in the 
locality described by Broca,. the third left frontal con- 
volution, or the insula of the same side. Agraphia, 
or inability to write, which may complicate alexia (ina- 
bility to speak), or exist as an isolated symptom, has 
been referred to lesion of the second frontal convolu- 
tion. In the absence of such lesion, the aphasic 
patient who cannot use spoken language, will remain 
able to express himself by writing. 

The various forms of aphasic symptoms help to 
localize the seat of a tumor, as of other focal brain 
lesions ; but they do not of themselves serve to dis- 
tinguish between tumor and softening ; and, therefore, 
can only point to tumor when associated with other 
symptoms. Unlike other symptoms, aphasia does 
not require discussion in relation to the relative liabil- 
ity of different regions of the brain ; for, as above 
shown, the presence of one or the other form, at once 
tends to assign the lesion to a definite locality. 

From the foregoing analysis of the causation and 
especial probabilities of diffuse and focal symptoms, 
it is possible, in a given case, to answer the two ques- 



122 TUMORS OF THE BRAIN. 

tions: first, Is there a brain tumor present? second, 
In what part of the brain is it situated ? 

I. Existence of Brain Tumor. — Although a 
tumor of the brain may develop either during child- 
hood or adolescence, let us suppose it to have begun 
its growth in an individual of middle age, who per- 
haps has shown a tendency to tuberculosis. In such 
a case we can assume that the clinical picture will be 
somewhat like the following : For weeks, or months, 
the patient will suffer from persistent or periodic 
headache, usually localized at one spot ; the pain is 
peculiarly severe, and is increased by percussion. 
After a time there will be attacks of vomiting, which 
sometimes coincide with the most intense paroxysms 
of pain, and sometimes do not. These attacks, fur- 
thermore, seem to bear no relation to the character of 
the food taken, or to the condition of the digestive 
organs ; they do seem, however, to be dependent 
upon changes in the position of the body, as, for ex- 
ample, from the recumbent to the upright position. 
As in the case of sea-sickness, the attacks are some- 
times incoercible. They are associated with vertigo ; 
and, in turn, the vertigo may occur independently of 
either the headache or the vomiting. It is apt to 
occur at intervals, and is often chronic in character. 
After the symptoms which have just been enumerated 
have lasted for a variable length of time, the patient's 
gait becomes uncertain ; he reels or staggers, or 
shows a tendency to fall forward or backward. This 
tendency sometimes increases until complete loss of 
equilibration renders the patient unable to stand, 
though he may be entirely free from paralysis. The 
muscles of one side of the face or of one arm begin to 
twitch, or even to be agitated by clonic spasms, which 



TUMORS OF THE BRAIN. 1 23 

may either persist all the time, except during sleep, 
or else may recur in periodic paroxysms, followed by 
paresis, gradually increasing to paralysis in the same 
muscles or in others, e. g., in the arm or leg, after 
twitching of the muscles of the face. The progress 
of the paralysis is apt to be interrupted by one or 
more convulsions, or by attacks of apoplexy or of loss 
of consciousness ; or one of these may usher in the 
first signs of paralysis, which, at the outset, may be 
complete, facial, monoplegic, or hemiplegic. Paraes- 
thesia or anaesthesia is next likely to manifest itself 
in the paralyzed limbs, or on the side of the face op- 
posite to these. Afterward the symptoms succeed 
one another in about the following order : alternate 
paralysis of cranial nerves and extremities ; devia- 
tions of the eyeballs. Isolated or conjugate ; dilatation 
of the pupils, ptosis, much more rarely appearance 
of Bell's paralysis ; occurrence at this time of di- 
plopia, hemlopia, or amblyopia, gradually increasing 
to complete amaurosis ; much more rarely deafness 
or anosmia, and the discovery of choked disk before 
or after the development of ocular symptoms ; pro- 
gressively increasing modification of psychic charac- 
ter — at first marked Irritability, then Impairment of 
mental powers, loss of memory, apathy or hallucina- 
tions, maniacal excitement, and melancholic insanity ; 
before or at the same time with the appearance of 
this mental change, there will be lesions of speech, 
dysarthria, aphasia, or word-blindness, the two latter 
often suddenly developed, as after an embolus, the 
first proportioned to the degree of tongue paralysis, 
and gradual. A patient presenting the foregoing 
assemblage of symptoms, all progressively increasing, 
has, with very great probability, a brain tumor. In 



124 TUMORS OF THE BRAIN. 

addition is to be noted the freedom from pyrexia, 
and usually from changes in the rhythm of either 
pulse or respiration. The gradual, sometimes rapid, 
emaciation, the fact that acute accidents, though 
often followed by an exacerbation of existing symp- 
toms, or even by the first appearance of new ones, 
have nearly always been preceded by others which 
have established themselves insidiously, are circum- 
stances important to the diagnosis. 

This being the general picture of the disease, in- 
dividual cases are framed by the special emphasis of 
one or more symptoms, or the obliteration of others. 
The individual peculiarities depend upon (i) the 
locality of the tumor, (2) upon its rate of growth, (3) 
upon its complications, (4) and, only to a very slight 
extent, upon its nature. 

Peculiarities Due to Locality. — These may be divined 
approximately from such an analysis as has already 
been given of the symptoms proper to lesions of each 
given locality. The a priori judgment must, how- 
ever, be modified in view of the tendency of tumors 
to encroach, in growing, upon territories adjoining 
their original seat, and also in view of the frequent 
diffusion of their influence beyond any situation 
which they may occupy. 

The following summary of symptom groups is ar- 
ranged in the order of characteristicness. It does 
not correspond to the order of frequency of locality, 
which, as indicated by the combined tables of Ladame 
and Bernhardt, would be as follows : 

Centrum ovale ...... 192 = 29 per cent. 

Cerebellum ...... 162 = 27 " 

Cortex . . . . . . . 74 = II " 

Pons 56 = S 



TUMORS OF THE BRAIN. 12$ 

Basal ganglia 36 = 5 per cent 

Medulla 30 = 4 " 

Corpora quadrigemina . . . . 13 = 2 '* 

Cerebral peduncle . . . . . 10 = i " 

Extra cerebral (including pituitary gland) . 71 = ii " 

649 

1. Tumor of Cerebellum Involving Middle Lobe, — 
Vertigo, vomiting, and headache, early, severe, and 
prolonged ; latter often occipital ; epileptiform con- 
vulsions of great violence, but not often repeated ; 
choked disk early, preceding amaurosis, but also fol- 
lowed by this ; deafness ; ataxic loss of equilibrium, 
tendency to fall forward or backward ; absence of 
motor or sensory paralysis ; intelligence clear till 
toward the end, when apathy gradually deepens to 
coma. 

2. Tum.or of Lateral Lobe of Cerebellum Pressing 
on Pons. — Similar symptoms to i, but complicated 
late in the disease by hemiplegia or hemianaesthesia, 
or both, or by alternate paralysis. Distinguished 
from pontine tumors by marked ataxia preceding 
paralysis. 

3. TuTnor of Pons, Lower Half, — Uncertainty of 
gait, rather than ataxia, succeeded by isolated paraly- 
sis of third, or sixth, or seventh, or twelfth nerve, 
not preceded by symptoms of irritation in the muscle 
which it supplies ; or else alternate paralysis, passing 
into incomplete paraplegia or general paralysis ; per- 
manent conjugate deviation of the eyes ; amaurosis in 
a third, choked disk in a fifth, of the cases ; entire 
absence of convulsions ; headache, vomiting, and ver- 
tigo milder than in cerebellar tumor, or absent, but 
intelligence affected in half the cases. 

4. Tumor of Upper Part of Pons. — Combination 



126 TUMORS OF THE BRAIN. 

of symptoms proper to cerebellum and pons, as lobe 
of cerebellum is frequently compressed. Isolated 
rather than conjugate paralysis of the third nerve ; 
paralysis of the facial on the same side as hemiplegia ; 
irritation of the trigeminus, sometimes of motor root, 
occasioning trismus ; or of sensitive root, causing 
neuralgia on the side opposite to the hemiplegia. 
Sudden death is especially frequent in tumors of 
the pons. 

5. Tumor of Cerebral Peduncle, or of Interpedun- 
cular Space. — Diffuse symptoms mild or absent ; com- 
plete hemiplegia, including buccal branches of facial, 
usually accompanied by hemiansesthesia on same side ; 
paralysis of motor-oculi nerve, causing divergent stra- 
bismus on side opposite to hemiplegia, this frequently 
passing over to opposite side. 

6. Tumor of Cerebral Cortex, or Upper Part of 
Centrum Ovale. — Epileptiform convulsions, frequent- 
ly repeated, but often brief and of moderate severity. 
Headache usually frontal, possibly on one side, severe 
at first, apt to gradually lessen ; choked disk infre- 
quent, vomiting and vertigo much less marked than 
with tumors of posterior fossa. Spasmodic twitchings 
or clonic convulsions, in face or limb muscles, followed 
by dissociate or monoplegic paresis increasing to 
paralysis, rarely accompanied by anaesthesia. Paraly- 
sis of tongue, hemiopia, or peculiar visual hallucina- 
tions, sometimes seen when tumor is in occipital lobe, 
but also, (once at least) when in frontal. Aphasia, es- 
pecially in connection with right hemiplegia. Word- 
blindness sometimes without paralysis, the tumor then 
being in the temporal lobe. Psychic disturbance in 
about half the cases (forty-nine per cent). 

7. Basal Ganglia, or Lower Part of Centrum Ovale, 



TUMORS OF THE BRAIN. 12/ 

— Complete hemiplegia, often followed by rigidity, 
thus resembling the hemiplegia of hemorrhage, ex- 
cept in regard to the more gradual development of 
the former. Sometimes associated with complete per- 
manent hemianaesthesia. Often complicated, late in 
the disease, with symptoms of intraventricular effu- 
sion ; thus, for example, there are convulsions, retrac- 
tion of the head, loss of consciousness, slow pulse, 
contracted pupils, as in acute hydrocephalus. 

8. Corpora Quadrigemina. — Individual cases can 
with difficulty be distinguished from tumors of the 
cerebellum. In the calculation of the probabilities, how- 
ever, the much greater frequency of cerebellar tumors 
(twenty-seven per cent, of the whole number as com- 
pared with two per cent.) is not to be forgotten. With 
tumors of the corpora quadrigemina, however, the 
percentage of headache, though high, is less so than 
with those of the cerebellum ; the percentage of vom- 
iting is higher ; convulsions seem to be so rare that 
their presence in a doubtful case would turn the scale 
against the corpora. The proportion of cases of 
choked disk is high, and of amaurosis, as also of 
psychical defect, higher than for tumors of any other 
locality (eighty-one per cent, of cases are amaurotic ; 
seventy-seven per cent, present psychic symptoms). 
Divergent strabismus from paralysis of the motor- 
oculi is sometimes present, and is then very charac- 
teristic. 

9. Medulla. — All symptoms ill-defined ; they re- 
semble those of tumors of the pons. Dysarthria, dys- 
phagia, and irritation of the cardiac and respiratory 
centres are more frequent. Paralysis of the vocal 
cords has been observed in a single instance. 

Besides the localities already mentioned, the clini- 



128 TUMORS OF THE BRAIN. 

cian must always inquire whether the tumor whose ex- 
istence is suspected does not spring from the cranial 
bones or the dura mater Hning them. Tumors of 
the anterior, middle, and posterior cranial fossae excite 
symptoms which approximately resemble those be- 
longing to the cerebral organs reposing in the same 
spaces. 

Anterior Fossa, — This comprises two regions, the 
sella turcica, with the pituitary gland and the optic 
chiasma, and the part anterior to this, upon which re- 
pose the frontal lobes of the hemispheres. In the lat- 
ter position tumors may cause exophthalmia on one 
or both sides. Apart from this, the characteristics 
are similar to those of tumors of the frontal lobes. 
Hemiplegia, spasms, and epileptiform attacks are in 
the background, while headache and vomiting play 
about the same part that they do in other tumors. It 
is asserted that the most notable symptom is psychical 
in character, viz., a peculiar childish alteration of 
character. 

Sella Turcica. — Although tumors in this region 
involve the pituitary gland, it is impossible to assign 
any special symptoms to lesions of that organ, whose 
functions are so entirely unknown. Patients suffer 
from severe frontal headache, but they manifest a 
striking apathy and drowsiness, without marked motor 
or sensory paralysis, or any disturbance of speech. 
From generalized pressure on the chiasma results 
double progressive amblyopia or amaurosis. 

When the tumor bears other relations to the chi- 
asma, it produces some species of hemiopia. If ante- 
rior to the chiasma, it produces a double temporal 
hemiopia, from compression of the fibres coming from 
the inner half of each retina. On one side of the 



TUMORS OF THE BRAIN. 1 29 

chiasma the tumor would only affect the outer fibres 
of one retina, or, if situated further back, so as to 
compress an entire optic tract after decussation — that 
is, all the fibres from the homonymous parts of the 
two retinae, as, for example, the right or the left halves 
of both eyes — it would produce homonymous hemiopia. 

Middle Fossa, — The most characteristic symptoms 
of a tumor of the middle fossa depend upon lesion of 
the trigeminal nerve. Thus, there may be unilateral 
anaesthesia of the face, unilateral weakness of the 
masticatory muscles, and, finally, if the Gasserian gan- 
glion be injured, neuro-paralytic keratitis of one eye. 
Through the medium of the chorda tympani branch of 
the trigeminal, the sense of taste may also be paralyzed. 

In addition to these most characteristic paralyses, 
there is frequently paralysis of the motor-oculi nerve, 
of the facial (five times out of nine), and of the acous- 
tic nerve — the latter usually by penetration of the 
tumor into the internal auditory canal of the petrous 
bone. With the facial paralysis there is degenerative 
electrical reaction. With these marked positive symp- 
toms are associated certain negative symptoms — 
absence of motor or sensory paralysis in the extremi- 
ties, absence of convulsions, absence or mildness of 
the headache or the vomiting. 

Posterior Fossa. — Tumors of this region cannot 
with any certainty be distinguished from those of the 
medulla, pons, or lower segment of the cerebellum. 
In one case a peculiar conjugated deviation of the 
eyes has been observed, the right eye turning upward 
and outward, the left inward and downward. This 
deviation recalls Magendie's experiment of section of 
the right lateral peduncle of the cerebellum ; and it is 
probable that this organ was involved in the tumor. 



130 TUMORS OF THE BRAIN. 

x\maurosis or amblyopia exists in one third of the 
cases — that is to say, even more frequently than in 
tumors of the cerebellum. But, in any individual case, 
this symptom can serve no purpose of diagnosis. 

Parts of Brain in which Tumors are most Fre- 
quently Latent. — Complete latency implies absence 
of all symptoms ; incomplete latency implies absence 
of focal symptoms only. The localities in which the 
latter condition is characteristically observed are also 
those in which tumors may most often be completely 
latent. These localities are : The temporal, occipital, 
or even, but less easily, the frontal lobes of the cere- 
bral hemispheres, provided the central gyri are not 
indirectly affected ; the parts of the centrum ovale 
corresponding to these regions, and hence untrav- 
ersed by fibres from the pyramidal tract ; the lateral 
lobes of the cerebellum, the thalamus opticus, and the 
lenticular nucleus. Finally, it is possible that in any 
portion of the brain a tumor may remain latent, pro- 
viding it grow slowly enough. 

Differential Diagnosis. — The epileptiform con- 
vulsions dependent upon cerebral tumor differ little 
or not at all from those of functional epilepsy. They 
are, however, often slighter, or at least the loss of 
consciousness is much less profound. The headache, 
on the contrary, is chiefly noticeable for its extreme 
intensity and persistence, in which respect it exceeds 
even nervous headaches. The vomiting is also 
noticeable for its violence, and for the absence of any 
other symptoms of disordered digestion, such as 
furred tongue, epigastric uneasiness, etc. The diag- 
nosis in regard to these symptoms ultimately depends 
on their combination, and on their association with 
paralysis or with psychical symptoms. Conversely, 



TUMORS OF THE BRAIN. I31 

the psychical symptoms of tumor are distinguished 
from pure mental alienation chiefly by the existence 
of these physical signs ; also by their greater vague- 
ness, which renders precise psychiatric classification 
difficult or impossible. 

It is by no means always easy to decide whether a 
patient with cerebral symptoms is suffering from a dif- 
fused or focal disease, and in the diagnosis of tumor 
it is necessary to exclude meningo-encephalitis, pro- 
gressive general paralysis, chronic basal meningitis, 
hydrocephalus, cerebro-spinal form of multiple scle- 
rosis, and locomotor ataxy. 

Tubercular meningo-encephalitis, which easily lasts 
three months, has, it must be remembered, a duration 
not inferior to that of many tumors, and many of the 
symptoms are identical : violent headache, convul- 
sions, vomiting, neuritis optica, changes of character, 
monoplegic paralysis, and spasms. In the diffused 
inflammation, however, these paralyses are transient 
and variable, a condition sometimes, but rarely, seen 
in tumor. The disease, moreover, is always attended 
by more or less fever, by more marked variations in 
the pupils, by a slow, hard pulse, by obstinate consti- 
pation, by retraction of the abdomen, aud by vaso- 
motor symptoms. When a tubercular tumor is asso- 
ciated with diff^used inflammation, it is masked by 
the symptoms characteristic of the latter. 

A tumor of the medulla may especially simulate 
progressive general paralysis by producing a diffused 
paresis without distinct paralysis, embarrassment of 
speech, depression of mental power, headache, and 
unequal dilatation of the pupils. A tumor, however, 
is indicated by the occurrence of amaurosis, convul- 
sions, vomiting, localized paralyses ; while the diffused 



132 TUMORS OF THE BRAIN. 

disease is characterized by the appearance of ambi- 
tious dehrium, and by the pecuHar trembling of the 
Hps. Tumors of the sella turcica may be closely 
simulated by chronic basal meningitis, which is most 
frequently situated in exactly the same locality, and 
also involves the same nerves. It is distinguished by 
the occurrence of descending optic neuritis, unat- 
tended by symptoms of intracranial pressure. In 
young children, premature closure of the fontanelles, 
with blindness, would point to meningitis ; enlarge- 
ment of the head, to tumor. 

Hydrocephalus may also have choked disk, and is 
usually associated with depressed mental capacity. 
Slow enlargement of the head belongs either to this 
disease or to tumor, in young children. The rolling 
down of the eyes and subsequent retraction of the 
head point to an effusion. Ventricular effusions are 
not infrequent complications of tumor, especially of 
tubercular tumor ; but the idiopathic disease does not 
occur except in very young children. 

Multiple cerebrospinal sclerosis may for a time 
simulate tumor, the disease being characterized by 
headache, vertigo, disturbances of speech and of 
vision (diplopia and amblyopia), and by the occur- 
rence of apoplectiform attacks, followed by incomplete 
hemiplegia. The latter, however, are rare in tumor, 
but are apt to be frequently repeated in sclerosis. In 
sclerosis, on the other hand, there is an absence of 
convulsions and of motor paralyses, except after apo- 
plectiform attacks. Instead, there is a diffused loss 
of power, with muscular rigidity, absence of vomiting, 
and choked disk. Finally, the appearance of the 
characteristic tremor of the limbs is a positive symp- 
tom which decides the question in favor of sclerosis. 



TUMORS OF THE BRAIN. 1 33 

Locomotor Ataxy, — It may occasionally be difficult 
to distinguish the ataxia of cerebellar tumor from that 
of tabes spinalis. But in the tumor the patient has a 
staggering or reeling gait, like that of a drunken man, 
and there is no sign of ataxy in either upper or lower 
extremities when the patient is in a horizontal posi- 
tion (Althaus). The alterations of sensibility, char- 
acteristic of tabes, are absent in tumor, and most of 
the positive symptoms of tumor are absent in tabes. 

Abscess of the brain, which, from its focal symp- 
tomatology, is ranked by Ball and Krishaber with 
tumors, sometimes simulates typhoid fever with pro- 
nounced cerebral symptoms. The absence of either 
pulmonary or abdominal symptoms, however, may 
prevent error, until the appearance of some localized 
paralysis decides the diagnosis. Two focal diseases 
of the brain often resemble tumor extremely — cerebral 
hemorrhage and softening. 

Cerebral Hemorrhage, — The onset of the paralysis 
is sudden, instead of being slow and insidious, and the 
paralysis is usually at once complete. But the cranial 
nerves are rarely affected, with the exception of the 
facial ; vomiting, headache, vertigo, and choked disk 
are absent, as are also mental symptoms after recovery 
from the apoplectiform shock. Hemorrhage into the 
meninges, which scarcely ever occurs except in chil- 
dren and old people, does not resemble tumor in any 
of its symptoms with the exception of convulsions. 

Softening. — The diagnosis from tumor is often ex- 
tremely difficult when the softening is, from the be- 
ginning, chronic in character. Lesions of special sen- 
ses are much less frequent in softening, and choked 
disk is rare ; so also are lesions of cranial nerves, 
vomiting and convulsions ; while the headache is less 



134 TUMORS OF THE BRAIN. 

circumscribed and intense. Contractures of paralyzed 
limbs are more frequent. Psychic alterations are 
marked, but are of a different character from those of 
tumor. There is emotional instability instead of irrita- 
bility, dementia rather than the depression and apathy 
of tumor. 

A diagnosis of the nature of the tumor can rarely 
be made. 

Carcinoma is often indicated by the rapid progress 
of the symptoms, and by signs of multiple foci succes- 
sively developing. Perforating tumors are almost in- 
variably malignant — carcinoma, sarcoma, or osteo- 
sarcoma. The tumor is nearly always primary, and 
destroys life before it has occasioned cachexia. 

Tubercular tumor often complicates tubercular 
meningitis, or is complicated by it. In either case 
the focal symptoms are much obscured by those of 
the diffuse disease. When isolated, a tubercular tu- 
mor may be suspected from the youth or scrofulous 
constitution of the patient. 

Gum,m.ata. — Their diagnosis principally depends 
upon the presence of other signs of syphilis. The 
evolution is relatively rapid, and the invasion of 
drowsiness and coma may be hastened by the co- 
existence of diffused endarteritis. 

Glioma. — This remains the most probable when the 
diathetic tumors have been excluded. It not infre- 
quently develops after a blow on the head, and then 
seems to result from chronic inflammation of the 
neuroglia. 

Intracranial anettrisms occasion symptoms which 
are indistinguishable from those of neoplasms proper. 
It is the basilar artery which is most often affected, and 
the symptoms then resemble those of tumors of the 



TUMORS OF THE BRAIN. 1 35 

pons. But all the arteries are liable to be the seat of 
this lesion. It is said that headache is more diffuse 
and more intense than with any other tumors, while 
vomiting is less frequent. Sudden attacks of loss of 
consciousness often occur, due undoubtedly to ine- 
qualities in the distension of the tumor, and conse- 
quent variations in the brain pressure. 

Aneurisms of the posterior communicating artery 
occasion symptoms of motor-oculi paralysis (ptosis, 
external strabismus, fixed dilatation of the pupil), and, 
finally, — the effect spreading to the corpora quadri- 
gemina, — amblyopia. When the aneurism is seated on 
the internal carotid, the sensitive root of the trigemi- 
nus may be affected ; hence neuralgias or anaesthesia. 
Aneurisms of the carotid which communicate with the 
cavernous sinus are characterized by exophthalmia, 
and a susurrus which is heard when the stethoscope 
is applied over the eyeball (case — Gruening), 

The termination of aneurismal tumors is peculiar, 
being always by rupture and sudden death, with the 
symptoms of intracranial hemorrhage. 

Abscesses of the brain comport themselves like an 
acute tumor. Their evolution is habitually much 
more rapid, and their progression much more regu- 
lar than that of neoplasms. There is sometimes 
fever, but often this is absent, and the tumor may be 
entirely latent for some time. An abscess is always to 
be suspected when localized cerebral symptoms develop 
in the course of an otitis media. Extremely chronic 
cases of this aural affection sometimes pass into an 
acute exacerbation, during which the cerebral mem- 
branes become infected through the roof of the tym- 
panum, through the fenestrse, or through the auditory 
canal. 



136 TUMORS OF THE BRAIN. 

Prognosis. — The prognosis of cerebral tumor is not 
modified by the diagnosis of either the seat or the na- 
ture of the tumor, unless the latter can be shown to be 
syphilitic. Gummatous tumors sometimes yield with 
remarkable rapidity to the mixed treatment for syphi- 
lis. All others are invariably fatal, but after a longer 
or shorter lapse of time, and with somewhat different 
modes of termination. Thus, as has been said, aneur- 
isms terminate by rupture, and death occurs with all 
the symptoms of cerebral hemorrhage. In the ma- 
jority of cases the patients die in coma, gradually de- 
veloped from a condition of apathy and drowsiness. 
These states are associated with continually increas- 
ing brain-pressure, which often results in oedema. 
Sudden death is not uncommon, and is dependent 
upon inhibition of the cardiac centre. This sudden 
death may occur as an accident after the most varia- 
ble duration of the disease ; but even the mode of 
death which seems to indicate the natural evolution 
of the morbid process, leaves a most variable time for 
this to be accomplished. The patient sometimes dies 
as early as ten or even eight weeks from the appear- 
ance of the first symptoms ; in other cases, these have 
been prolonged for ten years. 

Pathological Anatomy. — The histological struc- 
ture of many cerebral neoplasms, including aneurisms, 
does not differ from that of the same growths in any 
part of the body. Tubercular tumors, like miliary 
tubercle, always start from the lymphatic sheaths of 
the blood-vessels, beginning in a local accumulation 
of adenoid elements. Gliomata are a species of sar- 
comatous tumors, which are peculiar to the brain. 
They were described as neuromata, until Virchow de- 
monstrated that they contained no nerve elements, 



TUMORS OF THE BRAIN. T37 

but developed from the neuroglia. The glioma may 
consist almost exclusively of cells, and is then called a 
medullary glioma ; or it may contain a large amount 
of connective tissue, which either remains soft and of 
the myxoma type (myxoglioma), or becomes hard, 
fibrous, or even cartilaginous (fibrous glioma). Fi- 
nally, some among these tumors are so rich in vessels 
as to have acquired the name telangiectasic gliomas. 
All develop from the neuroglia. The tumor appears 
as a grayish mass, becoming pink or red as vessels 
develop in it. If these are numerous, apoplexies may 
take place into the substance of the tumor. The three 
forms of malignant tumor of the brain are sarcomas, 
carcinomas, and melanoid tumors. The first are 
closely related to the gliomas, arising like the me- 
dullary variety of the latter ; the chief difference con- 
sisting in the greater size of the cells and the larger 
amount of Intercellular substance. Cancer of the 
brain is nearly always encephaloid, primary, and not 
infrequently congenital. The growth is rapid, and 
the size ultimately attained by the tumor is in inverse 
proportion to the vital importance of the part of the 
brain in which it is seated. Enucleation of the tumor 
is impossible. Cancer of the upper part of the cere- 
bral hemispheres not Infrequently perforates the dura 
mater, and even the skull. Conversely, cancer of the 
eyeball, usually melanotic, constantly tends to pene- 
trate the brain. 

Melanoid tumors are forms of carcinoma In which 
the tissue is infiltrated with pigment. Their most fre- 
quent seat is the eyeball, the pigment being derived 
from that of the choroid. 

Hydatid cysts are found In the brain, but they usu- 
ally remain latent, especially If small and multiple. 



138 TUMORS OF THE BRAIN. 

Other forms of cyst are not infrequently formed by 
hemorrhagic effusion, by softening of brain-tissue 
from extensive necrobiosis, or by the softening of 
myxomatous tumors. 

Complicating Lesions. — With gHoma, congestion 
and hemorrhage in the vicinity of the tumor are the 
most frequent complications, the latter often being the 
cause of death. The tissue around the tumor is often 
the seat of an inflammatory softening. Effusion into 
the ventricles is often caused by compression of ves- 
sels which return blood from the choroid plexus. 
Such effusion is common with tubercle, and then 
may depend on granular thickening of the epen- 
dyma. 

A zone of non-inflammatory softening surrounds 
most tumors. It depends upon necrobiosis of nerve- 
tissue, from localized obstruction to the circulation, 
and oedema. When this softening is extensive, func- 
tional regions quite different fronl those actually occu- 
pied by the tumor become involved. This circum- 
stance, as has often been shown, by complicating the 
symptoms, often materially obscures the diagnosis. 

When the fibres of the pyramidal tract have been 
affected by the tumor, descending degeneration of 
secondary sclerosis may set in, and even reach the 
lateral columns of the cord. This is, however, much 
less common than after hemorrhage ; and, correla- 
tively, late rigidity is correspondingly rare. Con- 
versely, the appearance of rigidity in limbs paralyzed 
from the effects of a cerebral tumor, often indicates 
that hemorrhage has been excited in its vicinity. 

Treatment. — There is no radical medical treat- 
ment except for gummata, and for these the mixed 
treatment sometimes yields brilliant results. 



TUMORS OF THE BRAIN. 1 39 

The suggestion has recently been made to remove 
tumors situated near the surface of the brain by a 
surgical operation. The suggestion has been carried 
out in the following remarkable case (Bennett and 
Godlee, London Lancet, December 20, 1884) : 

Farmer, aged twenty-five. Symptoms lasted three years, be- 
ginning one year after a blow on the head. Paroxysmal twitch- 
ing of the left side of the face and tongue. General convulsions, 
then local spasm of the left arm, cessation of the convulsions, 
paresis of the arm, twitching of the left leg, violent headaches, 
attacks of vomiting, double optic neuritis. Patient trepanned at 
point of skull corresponding to upper (?) part of the fissure of 
Rolando. Dura divided, ascending frontal convolution exposed, 
and found to be distended. Incision of one fourth inch disclosed 
hard glioma, of the size of a walnut. Patient at once relieved of 
lancinating pains, vomiting, and convulsions, but paresis of left 
leg increased. Improvement up to twenty-first day. Then rigor, 
fever, nausea, and pain in head ; hernia cerebri. Death on 
twenty-eighth day. On post-mortem examination, signs of men- 
ingitis at lower portion of the wound, spreading downward tow- 
ard the base of the brain on the same side, the whole of which 
was inflamed and covered with plastic lymph. 



III. 



NOTE ON THE SPECIAL LIABILITY TO LOSS OF NOUNS 
IN APHASIA.' 

Some months ago, it occurred to me that it would be 
interesting to ascertain in how many cases of aphasia 
the defect bore upon any particular part of speech or 
mode of speaking. For this purpose I examined the 
records of one hundred and sixteen cases, and found 
that, among them, in seventeen, the patient had only 
lost the memory of noun substantives, or the faculty 
to employ these in voluntary speech. They were re- 
placed by a periphrase, in language often quite fluent. 
Among the ninety-nine remaining cases, in only two 
was any other part of speech systematically affected. 
In one, the patient had lost the adjective, but she had 
also lost the noun. In the other, the patient had lost 
control over pronouns, some of which, however, were 
used, but improperly, and only employed the infinitive 
of verbs. The seventeen cases are as follows : 

Case I. — Broadbent describes a patient, aged 77 at the time 
of death, who was seen at intervals between 1878 and 1883. His 
infirmity dated from a slight and fugitive attack of right hemi- 
plegia, predominating in the face, and accompanied by hemi- 
ansesthesia. There was at first a somewhat general disturbance' 
of speech, which finally became restricted to the loss of nouns. 
This defect persisted five years. During all this time the patient 
never uttered a noun but once or twice, and then inappropriately ; 
could say any thing else, and employ long phrases, so that they 

' Read at the Neurological Society, 1886. 
140 



LOSS OF NOUNS IN APHASIA. I4I 

did not contain a noun. When he wished for any thing he would 
say, " Please give me the one." ' 

Case II. was another of Broadbent's, similar in all respects to 
the first, except that the patient could not read.^ 

Case III. was also a patient of Broadbent's, a gas inspector, 
aged 59. The first complaint of this patient was, that he found 
himself unable to read, and could not remember names of places, 
persons, or things. Pointed to legs and arms, and said that he 
forgot the names of these. On another occasion, said that he 
could not recollect the name of this, taking hold of his coat. 
The doctor said " trousers." He said at first " yes," but then 
said " coat." Asking him afterward to name his finger, he mut- 
tered '' coat, hat, boot," then was silent. I suggested thumb. 
He said, ''yes, thumb," but afterwards " finger." This same pa- 
tient was able to give a lucid description of an accident which 
had happened to him seven or eight years before.' 

Case IV. is less striking, because the entire faculty of speech 
was much more compromised : The patient had a few favorite 
routine expressions, as " Ca va bien ; un petit mieux." He could 
not repeat the name of the objects shown to him, and made fruit- 
less efforts to do so. If he were told the name, however, he 
would recognize it as correct ; make a sign of affirmation, and 
observe, " oui, c'est 9a." But he could not repeat the word him- 
self.* 

Case V. — (Case of Dr. Allin, reported by Drs. Ball and Se- 
guin.^) The patient, after a third attack of cerebral accidents, 
recovered power of speech to a considerable extent, but had 
much difficulty with proper names and common names. Of a 
glass of milk he would say, "That is something to drink." 
Would have flashes of fluency on various subjects. With the prog- 
ress of convalescence, the patient's vocabulary increased. 

Case VI. — Trousseau describes an eminent lawyer who had 
the habit of frequently forgetting the name of the thing about 
which he wished to speak. Addressing his wife, he would say, 

1 Med. Chir. Trans., 1872. ^ j^id. 

' Med. Times and Gazette, 1885. ^ M. F. Balzer, Gaz. Med. de Paris, 1884. 
' Archives of Medicine, 1881, vol. iv. 



142 :note on the special liability 

" Give me tken my — my — sacr^ matin, my — you know very well." 
Then he would raise his hand to his head. " You want your 
hat?" "Yes, my hat." On another occasion, as he was going 
out, he rang the bell. " Give me my um — sacrematiit /" " Your 
umbrella ? " "Yes ; my umbrella." ^ 

Case VII. — Bateman,'^ quotes from Bergman {Zeitschrift fiir 
Psych., 1849) the case of a man, who, after a fall, lost the memory 
of proper names and common substantives. He retained memory 
of verbs, and was able by means of periphrases to express his 
meaning. 

Case VIII. — The same author also quotes from Graves (Dublin 
Quarterly, Feb., 185 1) the case of a farmer, who, after an attack 
of hemiplegia, could no longer employ nouns in his speech, 
though he always remembered the initial letter. 

Case IX. — This was one observed by Bateman himself, three 
years after accidents, which consisted exclusively in the sudden 
loss of speech. At the time of observation, the patient was able 
to talk, but not to use substantives except incidentally. Thus on 
being shown a purse, remarked : " I can 't say the word ; I know 
what it is ; it is to put money in." Here it is noticeable that, 
although the noun which was required as the object of the propo- 
sition could not be remembered or pronounced, yet another 
noun, money, referred to incidentally, could be named. 

Case X. — Lasegue ^ describes a priest from Canada, aged 65, 
who could relate his own history fluently, but used no nouns, or 
only with the greatest difficulty. 

Case XI. — Lordat relates the case of the naturalist Brousson- 
net, who only retained the use of two nouns, soir (evening), which 
indicated the future ; and juments (mares), by which he referred 
to a lady and her daughter. He replaced all other nouns, com- 
mon or proper, by periphrases, or by a series of adjectives. Thus 
he called one friend, "He whom I love well"; and another, 
"The great, good, modest one."* 

Case XII. — At an Academy discussion in 1873, Bouillaud 
mentioned a man, known to Cuvier, who had lost the memory of 

1 Peter, Gaz. Hebd., 1864. ^ Annales Med. Psychol., 1877 (Soc, Feb. 26th). 
"^ Aphasia. ^ Quoted by Bernard, " De I'aphasie," 1885, p. 185. 



TO LOSS OF NOUNS IN APHASIA. I43 

nouns, but was able, nevertheless, to compose phrases regularly 
and completely.^ 

Case XIII. — Piorry quotes the case of an abbe who had lost 
the memory of nouns. He would say " give me my — that which 
one puts on the — " then point to his head, showing that he meant 
his hat, or else " give me that which is worn to clothe one's self." 

Case XIV. — Bernard quotes another case from Bateman, where 
the patient, instead of scissors, would say, " that with which one 
cuts," and for window, " that by which one sees," or " that where 
it makes light." In this second expression, as in another case 
already quoted, the patient used a noun incidentally (light), but 
could not do so with deliberate intention. 

Case XV. — A patient of Gairdner's called Monday, "the first 
working day," his aunt, " his nearest relative on the mother's 
side." ' 

Case XVI. — This is described by Dingley. Five weeks after 
a slight attack of hemiplegia, patient was obliged to use circumlo- 
cutory phrases to describe objects. Thus, whenever shown the 
picture of a camel, he said, " Egypt long way." 

Case XVII. — Lichtheim relates a case of word deafness, 
where the patient talked a good deal in a flowing manner, though 
with some tendency to repetition of the same phrases, but he 
always had the greatest difficulty in naming objects, and assisted 
self by descriptive phrases. Thus, for wine he would say, " that 
is strong ; " for water, " that is weak." ^ 

From the foregoing list are excluded the much more 
numerous cases on record where the patient used the 
wrong nouns to express his meaning. For obvious 
reasons are also excluded cases where the entire vo- 
cabulary was extremely restricted. 

To any one who first begins to examine the records 
of published cases, it might seem as if a much larger 

^ Compt. rend. Acad, des Sciences, t. Ixxvii., 1873, 
2 Arch, de Med., 1866, 6e S., t. viii. 
' Brain, January, 1885. 



144 NOTE ON THE SPECIAL LIABILITY 

number could be collected of any given peculiarity. 
But all remarkable cases have done service many 
times, by being quoted over and over again by differ- 
ent authors, so that much care in verification is re- 
quired in order to avoid repeating one case as several. 
The peculiar form of aphasia under consideration 
has attracted much attention. Lasegue declared that 
the loss of the noun, " the substance of the discourse," 
was the most characteristic circumstance of aphasia.'' 
Bouillaud called attention to this peculiarity in his com- 
munication to the Academy in 1873 ; Chevreul, fol- 
lowing, offered an explanation of the fact. Falret, in 
1866,^ Bateman, in 1870 (quoting also an explanation 
by Osborne), Voisin in the '' Nouveau Dictionnaire " ; 
Bernard, in his monograph in 1884, all note that if 
any grammatical part of speech is systematically lack- 
ing to aphasics, it will invariably be the noun. Kuss- 
maul,3 I believe, makes a separate category of such 
partial aphasias, as do also Broadbenf^ and Lichtheim.^ 
'' The loss of the noun," observed Ross, '* is the most 
marked form of sensory aphasia." ^ '' It is evident 
that the amnesia progresses from the special to the 
general. It first affects the individual, the proper 
names, then the names of things which are the most 
concrete, then all substantives used in an adjective 
sense, — finally, adjectives and verbs which express 
qualities, states of existence, and actions." '' The 
idea of quality is the most persistent, because it is the 
first acquired and forms the basis of our most com- 

^ Loc. cit. 

^ " Dictionn. Ency." Art. Aphasie, 1866. 

^ " Die Storungen der Sprache in Greisen," 

* Medical Times and Gazette, June, 1884, also Med. Chir. Trans., 1872. 

^ Loc. cit. 

« " Handbook Dis. Nerv. Syst.," Philadelphia, 1885. 



TO LOSS OF NOUNS IN APHASIA. I45 

plicated conceptions " (Ribot, '' Das Gedachtniss " ; 
^translated into German from the French). 

The existence of this feature of language defect has 
sometimes seemed to conflict inexplicably with the 
common belief that children in learning to talk, learn 
nouns first. It is then supposed that the noun must 
be that part of speech which becomes the most firmly 
" organized " in the brain, and should therefore be 
the last to disappear when the brain is injured. Yet 
the reverse is certainly observed. 

The partial, or, as we may call it, the noun defect, 
is observed in amnesia (sensory aphasia). Case VI., 
from Trousseau's clinics, illustrates amnesia without 
aphemia ; the patient forgot the names of objects, but 
when told this name, he recognized it as correct, and 
was able to pronounce it. 

Case XIII. is precisely similar. In other cases, it 
is not stated whether the patients were able to repeat 
the name which they were unable to remember. The 
impression is conveyed in a majority of the histories 
that this could not be done. When the spoken word 
was nevertheless understood, it is to be inferred that 
there was no serious defect on the motor side of the 
speech mechanism, aud that the receptive, sensory 
side, was only incompletely injured. For in focal 
lesion of the auditory centre, spoken language sounds 
like gibberish to the patient. And where the power 
exists to repeat the word under the influence of the 
immediate stimulus from the auditory centre, this im- 
plies that the path between that and the co-ordinating 
centre of articulation is intact, and also that the latter 
centre is not seriously damaged. 

Two general inferences must be drawn, ist. That 
the lesion in these cases of partial defect is relatively 



146 NOTE ON THE SPECIAL LIABILITY 

slight 2d. That it involves the paths connecting the 
auditory with the concept centre, or those which asso- 
ciate the latter with the motor co-ordinating centre. 
These conditions would be fulfilled by a moderate 
diffused lesion or perturbation of the conducting tracts 
B M or A B in Lichtheim s schema. 

'' The lesion is amnesia," observes Lichtheim, " is 
not focal, but appears in more diffused morbid pro- 
cesses, or where cerebral circulation is deficient." The 
records of autopsies are not as useful as might at first 
be supposed, in solving the problems of this partial 
amnesia. To some of the most interesting recorded 
cases, no records of autopsies are appended. In the 
others, the lesions found belonged either to a period 
of disease from which the patient had partially recov- 
ered when he exhibited the partial defect, or to an 
exacerbation which preceded death, aggravated the 
symptoms, and determined the fatal issue. 

Thus it is really more profitable at present to ex- 
amine the question from the point of view of the 
mechanism of the naming process, considered in both 
its psychological and physiological aspect. Around 
the naming process have ranged some of the most 
celebrated controversies of philosophy. Whether the 
names of things, i. e., nouns, were used first, as 
Dugald Stewart ' asserts ; or whether the first v/ords 
were verbs, and indicated action, the theory of Adam 
Smith ; whether common names were evolved from 
proper names, or the reverse ; whether a class name 
represented a real existence apart from the individuals 
composing it ; or whether it stood for a real concept, 

' According to Dugald Stewart, the primitive men on seeing a wolf coming 
would cry, " wolf, wolf." According to Adam Smith, they would shriek, " he 
comes," and point to the beast in explanation (quoted by Max MuUer, " Science 
of Language," p. 31). 



TO LOSS OF NOUNS IN APHASIA. I47 

a conceivable notion of the mind ; or whether it were 
strictly a sign for a collection of attributes, these be- 
ing alone conceivable, — such questions as these racked 
the brain of humanity centuries before the cerebral 
localization of speech was dreamed of. That the ex- 
istence of a class name proved the existence of a real 
abstract being, an archetype upon which the individual 
members of the class were modelled, v/as the doctrine 
of the realists of antiquity and of the middle ages. 

But no one any longer supposes that the words 
man, or horse, or table corresponds to abstract but 
real beings, and this famous doctrine has no bearing 
upon the psychology of the naming process. It is 
otherwise with the second or conceptualist doctrine. 
This is constantly to be found cropping out, often un- 
consciously, from the most positivist descriptions of 
the mechanism of speech. In these, English physi- 
ologists, at least, usually assume the necessity of ex- 
plaining, first, how a concrete or general idea or con- 
cept is formed from sense impressions, then how a 
name becomes attached to this idea. The mode of 
attachment is sometimes very oddly expressed. Thus, 
Ferrier is quoted by Hammond as saying : ''The ideas 
of which words are the articulate symbols have no 
relation to that part of the brain where words are re- 
membered, except by associating fibres." ' We may 
justly ask what is meant by attaching an idea to any 
part of the brain. We might as well talk of connect- 
ing the time occupied by the run of a railroad train 
with the space it goes over. Broadbent,^ in an analysis 
of the mechanism of speech, in many respects most 

^ West Riding Reports. 1874 (quoted by Hammond, " Dis. Nervous System," 
Eighth Ed., 1886, art. " Aphasia"). 
* "Med. Chir. Trans ," 1S72, vol. iv. 



148 NOTE ON THE SPECIAL LIABILITY 

admirable, observes : " The conception or idea of ex- 
ternal objects is gradually formed by the fusion of the 
visual, tactual, and other impressions to which it gives 
rise. This idea is associated with an auditory impres- 
sion which has been used to designate it." If for the 
term of ''conception " we should substitute the other, 
" mental image," little would be lacking in Broadbent's 
description, at least from the standpoint of our present 
knowledge. Yet danger lurks in the term " mental 
image " also. The younger disciples of the purely 
materialistic school sometimes commit themselves to 
unintelligible absurdities by attempting too much 
precision in the history of " mental images." 

Thus Mile. Skwortzkoff, author of a good thesis on 
aphasia, and of an article on word-blindness, describes 
the evolution of the spoken word as follows : " Every 
object strikes several senses at once, and causes 
the development of as many sensitive images, whose 
totality constitutes the idea we have made for our- 
selves of this object. The impression forms in a first 
centre into a sensation, and this in a second cortical 
centre forms an image. The different sensitive images 
avQ^ransmz^^ed tow2irds the cQiitTQ for the formation 
of words (foot of the third frontal convolution and 
surrounding parts), where the totality of these images 
takes its formula, its name. This name, by means of 
fibres of transmission, reaches the medulla, whence the 
nervous fibres animating the diverse parts of the ap- 
paratus of phonation project it outwards.' But what 
is a name that it can be thus transmitted on nerve 
fibres like a messenger on the string of a boy's kite ? 

In this connection it is well to remember the caution 
of Hughlings Jackson : *' A method which is founded 

' Mile. Skwortzkoff, Archives de Neurologic, 1881, t. 11. 



TO LOSS OF NOUNS IN APHASIA. I49 

on classifications which are partly anatomical and physi- 
ological, and partly psychological, confuses the real 
issues." ' These mixed classifications lead to the use 
of such expressions as that an idea of a word produces 
an articulatory movement ; whereas a psychical state, 
an '' idea of a word " (or simply a '' word ") cannot pro- 
duce an articulatory movement, a physical state . . . 
We must keep these several sides of our subject apart, 
considering now the psychical side — speech, — and at 
other times the anatomical basis of speech. 

Speaking, then, exclusively on this anatomical basis, 
we may say, with Broadbent, that impressions made 
by the object upon the various perceptive centres of 
the brain, fuse together, after converging upon some 
cell area intermediate to these centres, into a complex 
impression of this object. When the object has been 
named at the time it was perceived, an auditory im- 
pression is made simultaneously with the visual and 
tactual impressions, and this fuses together with the 
rest. Now it is possible to revive the mental image 
of the object by reviving any one of the original im- 
pressions, or even the memory of these. Among 
these means of revival, that of the auditory impression 
or name is so frequently made, and has so many con- 
veniences, that it becomes the habitual sign of the 
rest ; and the name is used to draw into the conscious- 
ness of the person speaking or of the person addressed 
all the secondary or revived impressions of the sense 
attributes of the object.^ '' The word," observes 

^ Brain, Oct., 1878. " On Affections of Speech," Hughlings Jackson. 

^ " Whatever perfornas the office (of directing our attention to particular ele- 
ments in the perception) is virtually a sign ; but it need not be a word : the pro- 
cess certainly takes place to a limited extent in the inferior animals ; and even 
with human beings who have but a small vocabulary, many processes of thought 
take place habitually by other symbols than words. ... In many of the fam- 



150 NOTE ON THE SPECIAL LIABILITY 

Whitney, '' is simply the survival of the fittest, among 
a variety of resources, (gestures, etc.) for effecting the 
same purpose, namely, the mental revival of the attri- 
butes of an object.^ Thus, as Taine remarks, the as- 
sociation of a name with an object creates a couple, 
formed on the one hand by an auditory sign, on the 
other by the group of attributes with which the sign 
is associated. Of this couple, either member has the 
power of bringing the other into consciousness ; and, 
the first extension of mental processes becomes pos- 
sible when the sign may be substituted for the thing, 
and handled apart, like a mathematical symbol." 

In these descriptions, the word '' impression " is 
used with an intentional vagueness, to cover the un- 
known molecular processes which take place in the 
cortical sensory centres, in the intermediate cell areas, 
of, as Broadbent suggests, the non-sensory, the super- 
added convolutions, and in the innumerable tracts of 
nerve fibres which associate these together. Of these 
processes, we can only frame to ourselves a schematic 
representation. While for some purposes the term 
" images " answers well enough in this schema, ^ for 
others it is misleading, and the conception of a molec- 
ular vibration answers much better. It certainly is 

iliar processes of thought, and especially in uncultivated minds, a visual image 
serves instead of a word." John Stuart Mill. " Examination of Sir William 
Hamilton," 1865, vol. ii., p. 73. 

^Whitney, "Life and Growth of Languages," 1882. The author remarks 
that speech has the preference over gesture, even when it is less forcible and 
explicit, because it leaves the hands free. 

2 On Intelligence. Am. Transl., 1872, p. 6. " In the formation of couples, 
such that the first term of each suggests the second term ; and in the apti- 
tude of this first term to stand wholly or partially in place of the second, so as 
to acquire, either a definite set of its properties, or all those properties com- 
bined, we have, I think, the first germ of the higher operations which make up 
man's intelligence." 

•* It is constantly used by Meynert. 



TO LOSS OF NOUNS IN APHASIA. 151 

much more in accord with such analogies for nerve 
action as we are almost compelled to draw from the 
physical phenomena, sound, light, and electricity. 

The phenomena of musical combinations afford a 
guide at least for the schematic description of the 
name-evolution. The sound of the spoken name is 
certainly produced by air vibrations, which mediately 
impress the auditory nerve, and conceivably throw its 
molecules also into vibration. We may represent to 
ourselves these vibrations as continued to the cortical 
auditory centre, and there determining others, which, 
according to the special lines of intercellular fibres 
that are traversed, cause what Broadbent has called 
the specialized grouping of cells. These are not, of 
course, displaced in the nerve mass, but brought di- 
versely into relation with each other, in the same way 
as battery cells scattered through a laboratory may be 
diversely grouped according to the wires included, at 
any given moment, in the circuit. As far as our 
present data carry us, such a specialized vibration in 
the auditory centre would sufifice to bring the sound 
of the spoken word into consciousness. The " fusion" 
of this vibration with others analogous, coming from 
the visual and tactual centres is, as we must conceive 
it, analogous to the fusions of small groups of musical 
vibrations into larger groups, producing more com- 
plex sounds. This complex vibration, occurring in 
the so-called concept centre of Lichtheim, the super- 
added convolutions of Broadbent, does not ''produce 
an idea "/ it is itself the physical side or substratum of 
one phenomenon of which the conscious impression, 
idea, image, or concept, is the psychic aspect. The 
concept again, is not, as Sir William Hamilton de- 
clared, something conceivable by the understanding, 



152 NOTE ON THE SPECIAL LIABILITY 

though not by the imagination' ; ' but so far as it 
means any thing, it is the eqtiivalent of the mental 
image, or the psychic aspect of the com.plex vibration. 
This mental image differs from each sensory image 
by the very fact of its complexity, and also by its 
probable formation in non-sensory portions of the 
brain. It is these anatomical localities, and not the 
ideas, which are connected with the sensory centres 
by association fibres. Finally, the auditory impres- 
sion or vibration does not become a name in the audi- 
tory centre ; but only after it has become an integral 
part of the complex, fused vibration, whose psychic 
aspect is the idea of mental image. Hence a name 
in an unknown language is gibberish. The same 
consideration shows that the name is not affixed to 
the idea of an object after that has been separately 
elaborated. It is possible, it is true, to perceive an 
object whose name is unknown to the percipient. 
But, if the latter wish to communicate any impres- 
sions of this object to another person, he must make 
use of some sign to indicate it, and the sign, though 
but an indicative gesture, is already the essence of the 
word, and is simply replaceable by a verbal sign when 
that shall have been suggested. In the absence of com- 
munication, actual or potential, there is no language. 
Although a concrete name be the sign for a real 
mental image, composed of the remembered attributes 
of the object named, a general name is not. It is 
here that the modern philosophic doctrine of nomi- 
nalism becomes identified with the modern physiologi- 
cal doctrines of speech and thought. The philosopher 
may declare that there is no abstract conception in 
the mind, the physiologist that there is no material 

^ "Lectures on Metaphysics." 



TO LOSS OF NOUNS IN APHASIA. 1 53 

image In the brain, no matter how refined and ethere- 
alized. It is impossible to have an abstract concep- 
tion of a triangle that shall be free from any peculi- 
arities of some individual triangle, as a scalene or 
isosceles, etc. But it is possible to abstract the prop- 
erty of three-angledness from a class of figures, of 
which each individual possesses this, though possess- 
ing other properties besides. It Is this property or 
attribute that is recalled to the mind, and which the 
mind is capable of contemplating apart by means of 
the special verbal sign — triangledness — attached to it. 
"• Thus," observes Hamilton, '' a sign is necessary to 
give stability to our intellectual progress, to establish 
each step In our advance as a new starting-point for 
our advance to another beyond. A country may be 
overrun by an armed host, but it is only conquered 
by the establishment of fortresses. Words are the 
fortresses of thought." ' 

The internal mental image becomes realized in 
speech through further propagation of these (sup- 
posed) cerebral vibrations toward the point where 
they can determine such grouping of nerve cells as 
can secondarily regroup cells In the ganglionic centre 
immediately presiding over organs of phonatlon, — that 
is, towards the corpus striatum. All recent testimony 
tends to localize this point of convergence at the foot 
of the third left frontal convolution. The considera- 
tions which precede, suffice to show, however, the 
absurdity of regarding this convolution as the '' seat 
of the faculty of language." Broca himself only 
claimed that lesion of this convolution was followed 
by '* loss of the memory of the means of co-ordination 
that are employed to articulate words." '^ 

' Quoted by Mill, loc. cit. , p. 68. 

2 P. Broca, Bull. See. Anatom., 1S83, t. viii. (quoted by Bernard, loc. cit., 
P- 175). 



154 NOTE ON THE SPECIAL LIABILITY 

The far greater extension given to-day to the total 
cerebral mechanisms employed in speech, render super- 
fluous the criticisms upon Broca's doctrine which are 
based on the discovery of lesions of parts of the brain 
other than this convolution, and which have been 
found to co-exist with some form of aphasia.' 

I have not found any record of cases which show a 
loss of power to articulate names, when it was clear 
that these could be spontaneously recalled by the 
patient, and when, at the same time, other parts of 
speech could be articulated. 

When an object or a class of attributes constituting 
an abstract conception can be recalled to mind, but 
its name cannot, it is evident that the visual and tac- 
tual perceptions of the objects have persisted, while 
the auditory impression, or else its point of fusion 
with the rest, has been effaced. Chevreul says that 
this has happened because less attention has been 
paid to the name than to the sense attributes of the 
object. Ross, following Hughlings Jackson, says that 
names disappear first in the dissolution of speech, thus 
in the mildest cases, because they are less well organ- 
ized knowledge than that of simple relations.^ I think 
there is another reason which may be rendered clear 
by considering the primitive development of speech. 
It is highly improbable that this began in the use of 
either nouns or verbs, but rather in conglomerates, 
shorter or longer, which constituted an entire proposi- 
tion. Children, in learning to speak, use words at first 
with precisely this complex significance, and it is a mat- 
ter of accident whether the word employed be a noun, 

^ Thus Hammond, in the latest edition of his treatise, reproduces a table 
published by Seguin in 1868 (Quart. Joum. Psychol. Med., Jan., 1886), con- 
taining eighteen autopsies called in favor of Broca's theory, and thirty-four 
against. This merely refers to the cases with and without lesion of the third 
frontal convolution. ^ Loc. cit. 



TO LOSS OF NOUNS IN APHASIA. 1 55 

verb, adjective, or even a preposition. I knew a little 
boy, extremely intelligent, but who, at the age of two 
years, could only say five words, yet contrived to ex- 
press himself wonderfully well by gestures. But one 
of his few verbal signs was " hard-a-lee," an expression 
that he had learned while sailing, and which he habitu- 
ally used either to refer to a sail-boat, to urge a wish 
to go sailing, to announce his possession of a boat to 
a new-comer, etc. The verbal conglomerate was not 
learned first because it was simple or easy, for it was 
neither ; but it belonged to the circumstance that had 
made the most forcible impression on the baby's 
mind. 

According to Renan, many primitive languages 
abound in conglomerate expressions. The Green- 
lander treats an entire phrase like a single word, and 
conjugates this word like a simple verb. Among the 
majority of the North American Indians, continues 
the same author, the composition and agglutination 
of words is pushed to an almost incredible extent. 
Each phrase of these languages is only a verb, in 
which all the other parts of the discourse are inserted.' 
In the successive experience of both the individual 
and the race in the acquisition of speech, the order 
would seem to have been as follows : ist. There are 
the sensory impressions made by the qualities of the 
object. 2d. A proposition arises in some one's mind 
to be communicated about this object to another per- 
son by means of a verbal sign, more or less extensive 
in significance, but probably always at first unique. 
3d. There is a gradual breaking up of this con- 
glomerate sign into words occupying special relations 
to each other. 

' " De r origine du Langage," Sixth Edition, 1S74, p. 156. 



156 NOTE ON THE SPECIAL LIABILITY 

Whitney observes that the establishment of a clear 
distinction between the noun and the verb especially 
marks the genius of the Indo-European languages, 
and it is not nearly so well marked in others.' In the 
development of these languages, words originally 
betoken qualities— the most general circumstances, — 
which are gradually specialized and individualized 
towards concrete objects. Thus, although the hypo- 
thesis be provisionally useful for the purpose of 
analysis, it is probably not really correct to say 
that the process of naming ever consists in fusing 
a verbal sign merely with the sensory impressions 
of a single object. The conglomerate verbal sign 
was evolved from original interjectional sounds, 
under the pressure of a strong desire of communica- 
tion with a fellow-being. For this very reason, the 
sign must always have implied a proposition concern- 
ing the object referred to. So long as the primitive 
man simply recognized the wolf, and took his own 
precautions for defence, there was no language. Lan- 
guage began when men began to concert together for 
defence against a common enemy. The very least 
that could then be said was, '' There is the wolf," or 
'' the wolf comes," complete propositions involving a 
subject and a predicate, but both probably expressed 
together by a single conglomerate sign. This sign 
represented the fusion of an auditory impression, not 
only with the group of visual impressions which made 
up the general mental image of the wolf, but with the 
visual impressions of events in which the wolf took 
part. At the present day, though the original con- 
glomerate be broken up into separate words, the 
phrase still retains its unity in thought. If from lesion 

^ " Life and Growth of Language." 



TO LOSS OF NOUNS IN APHASIA. 1 5/ 

of the associating fibres through which diverse im- 
pressions may be fused, this unity is weakened, and 
the phrase threatened with dissolution, the part which 
first tends to disappear is that which is most easily re- 
placeable by the visual image. This is certainly the 
part of the phrase of conglomerate sign which indicates 
the object itself. The speaker can point to it when 
in sight, can describe it by periphrases when it is out 
of sight ; but such replacement is possible for nothing 
else in the proposition. As long, therefore, as speech 
is possible at all, it will express by verbal signs those 
parts of the proposition which cannot be expressed in 
any other way, while the name which can be diversely 
suggested is forgotten as a simple sign. As Kussmaul 
observes : '' Conceptions of persons and things, are 
more loosely associated with their names than the 
abstractions of their conditions, relations, and proper- 
ties. We can represent persons and things to our- 
selves without their names ; . . . but more abstract 
ideas are only grasped by the help of words. So 
adjectives, pronouns, adverbs, prepositions, conjunc- 
tions are much more closely associated with thought 
than are substantives. We may suppose that in the 
reticulum of the cortex far more numerous excitation, 
processes and combinations are necessary to shape an 
abstract than a concrete idea." (Die Storungen der 
Sprache.) 

Ribot adds : '' The persistence of verbal signs in 
memory is proportioned to their degree of organiza- 
tion — that is, the number of repeated and registered 
experiences." 

Temporary forgetfulness of a name is, as is well 
known, not at all uncommon among quite healthy 
people. Any one, by observing himself closely in 



158 NOTE ON THE SPECIAL LIABILITY 

these cases, may recognize that the difficuhy of recall- 
ing the name seems to be directly proportioned to the 
clearness of the visual image of the object. As an 
example : I found myself the other day telling a per- 
son to go down on the piazza, and stammering over 
the word " piazza," while I was at the same time pic- 
turing to myself the locality with unusual distinctness. 

The patients who recall the names of objects that 
are incidentally imbedded in the phrase describing an 
object whose name they cannot recall, illustrate the 
theory here advanced. When such a one says, upon 
seeing a purse, " I know what it is, but cannot name 
it ; it is to put money in," the noun, '' money," is 
merely part of an adjective phrase which might be 
expressed *4t is money-containing." 

The name recalls the properties of money so faintly 
that the visual image of this object cannot triumph 
over the verbal sign and obliterate it. But the object 
in view, the object of the entire proposition, excites a 
visual impression so much more powerful than the 
auditory sign belonging to it in the verbal conglom- 
erate — the phrase, — that this sign is obliterated. It is 
not, of course, that the visual impressions or memories 
are absolutely increased in strength ; they become re- 
latively stronger simply because the mechanism for 
the revival or for the association of all verbal impres- 
sions is damaged, and these, therefore, are weaker. 

It seems to me that this theory is much better 
grounded than that which attempts to distinguish be- 
tween the words which " are better organized in the 
brain" and those which are less so. No auditory 
sounds, however highly specialized, are words, until 
they are understood as the signs of things, or of the 
relations of things. And no words are, in themselves, 



TO LOSS OF NOUNS IN APHASIA. 1 59 

any fixed part of speech, but only exist as words in the 
relation they occupy to the mental grouping of the 
moment. 

It is this relation which first disappears in sensory 
aphasia, while enough of the mechanism for record- 
ing verbal auditory impressions remains to enable the 
patient to recognize a name pronounced before him. 
The association of this verbal sign with the visual im- 
pressions of an object may be so much damaged that 
revival of the one in consciousness will not recall the 
other. The psychological difficulty depends on physi- 
cal injury to the anatomical tracts which connect the 
visual and auditory centres. 

In the conglomerate mental image framed of the 
object and of a proposition concerning it, there will 
persist the reminiscence of the sense impressions of 
the object and the auditory signs used for enunciating 
the proposition. These signs have never been con- 
nected with any particular visual impression, but only 
with a series of relations whose memory is registered 
or organized in the concept, supra-sensory centre. In 
the milder forms of sensory aphasia the paths be- 
tween these intellectual centres and the auditory cen- 
tre on the one hand, and the motor centre on the 
other, are presumably intact ; no dislocation takes 
place between the auditory signs and the series of re- 
lations to which they correspond. The name of the 
object is, however, entirely dislocated from its ha- 
bitual associations ; the impulse or vibration which 
passes from the visual centre goes directly to the con- 
cept centre, without fusion with any impulse coming 
from the auditory centre. The final mental conglom- 
erate of the proposition, therefore, which is to be ex- 
pressed, consists partly of reminiscences of sense im- 



l6o LOSS OF NOUNS IN APHASIA. 

pressions, partly of revived verbal signs, instead of 
being composed entirely of verbal signs, as is normal. 
The verbal signs which remain in the conglomerate 
are repeated by the articulatory mechanisms which 
receive the appropriate stimulus to functional cell 
grouping. The visual reminiscences of the object 
cannot be expressed by these mechanisms, any more 
than waves of sound could be reproduced by the 
retina, or waves of light by the auditory nerve. This 
substantative portion of the conglomerate proposition 
can only be expressed by gestures or by visual signs. 
Such signs must have served the purpose of expres- 
sion before any auditory signs had become special- 
ized into speech. They serve such purpose again 
when auditory signs have become disassociated with 
objects on account of lesion of the anatomical paths 
through which visual and auditory impressions may 
fuse together. The dissolution of speech follows the 
reverse order of its development ; the concrete names, 
the last framed, fail first. 

It has been suggested to me by a friend who list- 
ened to the exposition of the foregoing theory, that, 
in accordance with it, abstract nouns, as "love," 
*' patriotism," "virtue," should be retained by the 
aphasics in question, because they are associated 
with no definite visual image, but with series of 
relations. It would be interesting to test this sug- 
gestion. 



IV. 

CASE OF NOCTURNAL 
(Reprinted from The Journal of Nervous and Mental Disease, July, l88o.) 

The case of rotary spasm I have asked permission 
to describe to the Society, exists in a boy of three 
years of age, remarkably chubby, and presenting the 
appearance of the most perfect health. Since his 
birth, he has never had any illness except a mild at- 
tack of scarlatina, which occurred six months after the 
first development of the present affection. This be- 
gan at the age of eighteen months — thus eighteen 
months ago. The mother then noticed that, after the 
child had been asleep for a couple of hours, he would 
turn over on his right side, drawing the right arm 
above his head, and applying the left hand over the 
left ear. Once in this position, he would begin to os- 
cillate his head on the pillow from right to left, in a 
perfectly rhythmical manner. The oscillation would 
be maintained for about half an hour, and then the 
child slept quietly again. From the time this phe- 
nomenon was first observed, no night passed without 
its occurrence ; but for the first six months, the rotary 
movements were not very rapid — did not last very 
long — and thus did not attract any great attention. 
They were ascribed to a morbid habit of no especial 

' Read before the New York Neurological Society. 
i6i 



l62 CASE OF NOCTURNAL ROTARY SPASM. 

significance. During the last year, however, — thus 
ever since the attack of scarlatina, — the oscillation has 
increased in rapidity, in duration, and even in extent. 
At first exclusively confined to the head, the rotation 
has successively involved the shoulders and the trunk. 
At first confined to half an hour, it now habitually 
lasts several hours, and even the whole night. 

It is noticed that if after the paroxysm had begun 
at nine and lasted an hour, the child was awakened, 
he would sleep quietly until midnight, but that then 
the movement would recommence and become most 
violent between five and six in the morning. After 
that he would fall into a very heavy sleep, and instead 
of awakening early, as usual with children of this age, 
the boy would sleep till 7^ or 8. 

Change of locality would generally diminish the 
violence of the nocturnal movements for a few nights. 
But they would then regain their original intensity ; 
often the thumping of the crib as the child rolled from 
side to side would make a noise suf^cient to keep 
awake the mother or nurse in an adjoining room. 

In the morning following a night thus agitated, the 
child would seem to be in nowise fatigued, and cer- 
tainly retained no recollection of his nocturnal gyra- 
tions. He never could be induced to repeat them vol- 
untarily, though he had become impressed with the 
solicitude they excited, and would often threaten to 
" shake his head," in order to tease his mother. He 
would even, when requested, lie down in the position 
in which the paroxysm habitually occurred, on the 
right side, with the right arm above the head, and the 
left hand applied to the left ear. But in this position, 
while awake, no attack occurred ; although the invarl- 
ableness with which the attack during sleep was pre- 



CASE OF NOCTURNAL ROTARY SPASM. 1 63 

ceded by the assumption of this position, suggested 
some connection between it and the rotary spasm. 

In view of such a possible connection, on the first 
occasion on which I witnessed the phenomenon, I 
turned the child on the left side. The movements im- 
mediately ceased, and on that occasion — a nap taken 
in the daytime — did not return. The mother reported 
that this manoeuvre had often been tried, and always 
with the effect of temporarily checking the rotation. 
The child resisted the turning with considerable force, 
and, as soon as left to himself, turned over on his right 
side, and recommenced his oscillations. 

It was noticed that the paroxysms rarely occurred 
when the child slept in the daytime, or if they did 
they were of very moderate severity. But this fact 
seemed dependent on the other, that the rotations 
only took place during a very sound sleep, and after 
this had lasted about two hours. 

On the first occasion on which I saw the child, how- 
ever, he had been brought from some little distance in 
the country, was very tired, and readily went to sleep at 
noon. The rotations of the head began in half an hour. 

Starting from the attitude of repose on the right 
side, the head was thrown to the left and a little up- 
wards, with a slight jerk, so that the face looked up- 
wards and to the left, the occiput downwards and to 
the right. It was then immediately restored to its 
former position, so that the face worked downwards 
and to the right, the occiput upwards and to the left. 
These positions were alternated seventy-two times in 
a minute, and were rhythmically regular. The move- 
ment from right to left, which seemed the initial 
movement, was always jerking, the movement of 
restitution, from left to right, was not. Accompany- 



164 CASE OF NOCTURNAL ROTARY SPASM. 

ing the oscillations of the head were twitchings of the 
eyelids, and apparently oscillations of the eyeballs. 

The first half of the oscillation was necessarily ef- 
fected by sudden, brief contraction of the right sterno- 
cleido-mastoid, together with the clavicular portion of 
the right trapezius, and probably also of the splenius. 
(Duchenne, pp. 2, 714, 715.) The second half of the 
oscillation, or the movement of restitution, necessi- 
tated similar contractions on the part of the homolo- 
gous muscles on the left side. Faradization (after 
Duchenne's method) of the right sterno-cleido-mastoid 
muscle of a healthy woman lying on the back, rotated 
the head upwards and to the left with a jerking mo- 
tion, in a manner entirely resembling the first half of 
the oscillation in our case. 

During this oscillation the forehead of the child was 
slightly contracted, and a very slight shade of distress 
seemed to be impressed on the child's features. The 
pulse was ^j^ soft and regular. The temperature of 
the left parietal region, alone accessible with the pa- 
tient in position, was 94.5° (94.4° G.). After watching 
the oscillation for fifteen minutes, and observing no 
change, I turned the child carefully on the left side. 
All movements immediately ceased, both of head and 
eyelids, and the child continued to sleep tranquilly. 
The mother attributed this result, unusual in her ex- 
perience, to the unusual degree of fatigue caused by 
the journey. 

Immediately on turning the child on the left side, I 
noticed a considerable change in the pulse. It in- 
creased in fulness and strength, and in frequency to 
115. In five minutes it had fallen to 99, and became 
much softer. In ten minutes it had returned to the 
original rate of 87. 



CASE OF NOCTURNAL ROTARY SPASM. 1 65 

While the child lay on the left side the parietal 
temperature of the right side was measured, and 
found to be 93.° (93.59° G.). The temperature of the 
occipital region was 95.° (91.94° right, G.). Thus this 
portion of the head was 3.06° higher than the average 
temperature for the occiput as given by Dr. Gray. 

After about fifteen minutes the child was turned 
over again on the right side ; but the oscillation did 
not return. No change was noticed in the pulse, such 
as had been observed after turning the child in the 
opposite direction : it remained soft, and at 87 beats 
in a minute. 

A few weeks later I had an opportunity of observ- 
ing a nocturnal paroxysm. This began punctually at 
9, the child having fallen asleep at 7. At first the 
rotation was confined to the head, and resembled that 
already described. But a little later, after some in- 
terruption, the movement changed. With the left 
hand over the left ear, the child began rotating the 
entire upper half of his body, softly, rhythmically, 
about seventy times a minute. The head moved with 
the shoulders and trunk ; the lower limbs remained 
quiescent. A little later in the evening this rotation 
was accompanied by a crooning cry, also rhythmical. 

The child had the air of rocking himself to sleep to 
his own lullaby. 

This cry was a feature in the case that had only 
recently been added. It reminded me of one that I 
once heard uttered by a child during the clonic period 
of an eclamptic convulsion. The child was suffering 
from intermittent fever, and very often had convul- 
sions at the time of the chill. Whenever these con- 
vulsions were severe, the automatic inarticulate crying 
would begin, and gradually shape itself into a tune, 



1 66 CASE OF NOCTURNAL ROTARY SPASM. 

which was always the same, namely, '' Pop goes the 
Weasel." The inarticulate crooning of the child 
whose case we are nov/ describing was modulated 
into no definite melody. But, like the above, it 
seemed to depend upon a succession of clonic con- 
tractions of the constrictors of the glottis, analogous 
to the contractions affecting the other muscles. 

During this nocturnal attack the face of the child 
became very much flushed, as had not been the case 
during the first two hours of sleep. The mother re- 
ported that this flushing was a constant accompani- 
ment of the rotation, though it had not existed during 
the mild attack I witnessed in the daytime. 

The temperature at the occiput was 96^° — thus still 
higher than had been observed on the previous occa- 
sion. 

In the daytime, careful examination of the child, 
especially in regard to motor incoherences or ataxia, 
or to any disturbance of the special senses, yielded 
completely negative results. The expression and 
gestures were vivacious and intelligent. The artic- 
ulation, however, was more defective than usual for 
children of three years old. Until the age of two and 
a half, its speech was said to have been completely 
unintelligible. 

The head of the child presented no marked ab- 
normality of shape. The forehead, however, was 
projecting, and the palate much arched. 

The inquiries in regard to the faculty of equilibra- 
tion and to the sense of hearing, were especially sug- 
gested by the resemblance which the rotatory move- 
ments of the child bore to those which, in animals, 
follow unilateral section of a lateral peduncle of the 
cerebellum, or of the horizontal branch of the semicir- 



CASE OF NOCTURNAL ROTARY SPASM. 167 

cular canals. Such mutilation Is apt to be followed, 
not only by rotations of the head, but also by rota- 
tions of the entire trunk, and are accompanied by os- 
cillations of the eyeballs. Clinically speaking, there 
can be no doubt that the morbid condition belongs to 
the group of choreiform affections, of which the sa- 
laam convulsion or spasmus nutans, and the saltatory 
convulsion, are the types. 

In the spasmus nutans, both stern o-cleldo and mas- 
toid m.uscles are affected, and hence results a nodding 
movement of the head. '^ But when," observes Eu- 
lenburg, '' there is unilateral clonic convulsion of the 
same muscles, the movements are rotatory. The 
point of the chin is turned towards the sound side ; 
the occiput is drawn down ; the ear and mastoid pro- 
cess approached to the clavicle of the affected side." 

As already noticed, this movement can be exactly 
imitated on a healthy person who is lying down, when 
one sterno-cleido mastoid is Intermittently faradized. 
Eulenburg further notices that these clonic spasms 
are often not isolated, but are accompanied by con- 
tractions of the muscles innervated by the facial, tri- 
geminus, and oculo-motor nerves. The movements 
are sometimes very slow, sometimes as rapid as lOO a 
minute. 

Erb describes a rotation of the chin from one side 
to the other, occasioned by alternate spasm of both 
sterno-cleido mastoids. He asserts that the bowing 
movement caused by an exactly synchronous action of 
the same muscles, is much less frequently observed. 

Soltmann, in Gerhardt's new encyclopaedia, also de- 
scribes two forms of '* spinal-accessory convulsion." 
It consists, he says, in a double or rhythmically alter- 
nating contraction of the antagonists, whereby the 



1 68 CASE OF NOCTURNAL ROTARY SPASM. 

head Is now turned from one side to the other, or else 
the chin is alternately depressed or elevated. 

In 1850, Dr. Willshire read a paper on The Eclamp- 
sia Nutans, or Salaam Convulsion, in which he stated 
that there were only four well authenticated and de- 
tailed cases on record, those namely described by Dr. 
Newnham in 1839. ^^ these cases, three children 
died and one recovered. The latter was sixteen 
months old when she began to have attacks of " head 
nodding " three times a day. The paroxysms rapidly 
increased in number and severity, and the convulsive 
movement extended to the trunk, which was forcibly 
bowed, sometimes as often as 140 times a minute. 
The paroxysm seemed to occasion considerable suffer- 
ing, and was followed by exhaustion and drowsiness. 
After three months, the child lost the ability to crawl 
she had previously acquired. A month later, the at- 
tacks began to come on during sleep, from which the 
child would avv^aken with a violent scream, and in a 
spasm of the whole body, the head being first thrown 
back and then bowed violently to the feet, which were 
also drawn upwards. Six months from the beginning 
of the attacks, the child fell into a comatose sleep 
which lasted some hours, and from this date improve- 
ment commenced. The clonic convulsions ceased al- 
together, but the intellectual development of the child 
was arrested, so that at three years she was no more 
advanced than at two. 

In Dr. Newnham's other cases the children became 
hemi- or paraplegic, and completely idiotic. 

In Dr. Willshire's case the child was only six months 
old when the bowing movements of the head began. 
These were repeated fifty times a minute, and were 
so extensive that the head was made to touch the 



CASE OF NOCTURNAL ROTARY SPASM. 169 

knees. These paroxysms always occurred after sleep, 
and were severe in proportion to the intensity of the 
sleep. They never occurred during sleep. Occa- 
sionally they were replaced by general epileptiform 
convulsions. This case recovered under a treatment 
of purgatives, blisters behind the ears, iodide of po- 
tassium and quinine. 

Dr. Bidwell's case, reported in 1852, terminated as 
unfavorably as did the three cases of Dr. Newnham. 
The nodding movements began at the age of six 
months, occurring three to four times a day, being at 
first repeated only a few times in the course of a 
minute or two. At the age of a year, the frequency 
and intensity of the paroxysms had increased, consist- 
ing of thirty or forty convulsive movements in rapid 
succession. By this time it became evident that the 
mental development was very much retarded, if not 
wholly arrested. The slight nod of the original 
paroxysm increased to the true Oriental '* salaam," in 
which the head was suddenly drav\^n quite down to the 
floor, often bruising the forehead and lips. Later, 
epileptic convulsions occurred, and at the end of sec- 
ond year the child was hopelessly idiotic and epileptic. 
She died at the age of twenty-six months. No 
autopsy recorded. 

In 1850 Dr. Faber reports a case, in a child of three 
years, whose health had begun to suffer only three 
months before coming under observation. The nod- 
ding paroxysms came on suddenly, after much com- 
plaint of headache and drowsiness, and were accompa- 
nied by strabismus. The nodding paroxysms merged 
into epilepsy, and the child became idiotic. 

In a second case observed by Faber, the patient, a 
child of six years, was severely frightened by falling 



I/O CASE OF NOCTURNAL ROTARY SPASM. 

down a well. After that he seemed to droop ; his 
sleep was restless, and he frequently cried out in it. 
One day, having been scolded by his father, he began 
to nod his head violently, while at the same time the 
face was distorted. The nodding movements oc- 
curred about eighty times a minute ; the paroxysm 
lasted three or four minutes and returned several times 
a day. At its close the child was evidently much fa- 
tigued. A condition of stupidity supervened, analogous 
to that occurring in chorea. Ultimately, however, 
the child improved under the administration of iron. 

In 1867 Dr. Morgan published in the Lancet a case 
of rotatory cramp of the head, observed in a man 
thirty-eight years old. Since childhood he had suf- 
fered from headache and from a choreatic affection of 
the right arm, which prevented him from writing. A 
rotatory cramp of the head developed after exposure 
to cold. While in bed, or while sitting or standing, 
this was very slight, but so soon as patient began to 
walk, the chin was convulsively drawn to the shoulder, 
the head inclined to the opposite side, while severe 
pain was felt both in the neck and also in the occiput. 
The occipital tuberosity was painful on pressure. Dr. 
Morgan considered that the convulsive rotation was 
principally effected by the left sterno-cleido-mastoid 
and right trapezius muscle ; and, acting on this theory, 
he cut the left spinal-accessory nerve, paralyzing the 
trapezius and sterno-mastoid on the left side. After 
the operation, although the trapezius, with the splenius 
and complexus, still remained affected, the patient 
was able to walk without a convulsion, if he took the 
precaution to hold the clavicular fibres of the trapezius 
between his fingers. 

In 1868 Henoch described cases of spasmus nutans, 



CASE OF NOCTURNAL ROTARY SPASM. I /I 

not limited to the head, but involving the entire upper 
part of the body. In one case the nodding convulsion 
alternated with lateral movements of the head from 
right to left. Nystagmus often coexisted. One of 
Henoch's cases was ameliorated in fourteen days. 
The other terminated, suddenly, in death. 

The latest recorded cases that I have been able to 
find are by Kropff, reported in 1877, in an inaugural 
dissertation. . The first was in a consumptive woman, 
attacked by the convulsion during the puerperal state. 
The convulsion was accompanied by pains in the 
region of the left occipital and the frontal nerves, and 
consisted in nodding of the head seventy or eighty 
times a minute. At the same time the head was 
turned a little to one side. Voluntary movements 
were possible, and the clonic contractions could be 
passively overcome. The morbid condition was cured 
by tonic treatment and by iron. 

The second case was in a man, in whom the head 
was thrown first directly backwards, then forwards. 
The spasm lasted only a second, but was repeated 
twenty or thirty times a minute. It was succeeded by 
a tonic spasm of the constrictors of the glottis, so that 
the breathing was arrested for a few seconds ; then by 
clonic spasm of the pectoral and deltoid muscles, caus- 
ing involuntary movements of one arm. From these 
cases it is evident that the spasmus nutans and the 
spasmodic affections allied to it may be either purely 
functional disorders, or else symptomatic of organic 
cerebral disease, as in the earlier cases described by 
Newnham, Willshire, and Bidwell. As far as can be 
at present ascertained, the case I have described be- 
longs to the first category. But it differs from them, 
and from all of which I can find a record, in two 



172 CASE OF NOCTURNAL ROTARY SPASM. 

important particulars, ist. The rotatory paroxysms 
occur in the recumbent position and during sleep ; 
while in the other cases recumbency has quieted, and 
sleep arrested, the paroxysms. 2d. The rotatory 
spasm in our case exists only so long as the body is 
maintained in a certain position. 

Is it possible to draw any diagnostic inference from 
these two facts ? 

The occurence of the paroxysm during profound 
sleep, its intensity during the early morning, and the 
profound sleep by which it is followed, the flushing of 
the face, and the inarticulate cry accompanying the 
rotatory spasm, suggests many analogies with epi- 
lepsy, which, in the absence of organic lesion, might 
justify us in classing the affection as an epileptiform 
rather than as a choreiform neurosis. For the occur- 
rence or non-occurrence of morbid symptoms during 
sleep is well known to be one of the most striking 
points of contrast between the symptomatology of 
epilepsy and of chorea. 

It may be mentioned in this connection that the 
only medicine which has in any way seemed to con- 
trol the paroxysm is bromide of potassium ; this 
even when given in small doses. On last seeing the 
child, he was ordered a mixture of bromide and 
chloral : ten grains of bromide and five of chloral 
twice a day — twenty grains of bromide and five of 
chloral at night For ten days after taking this 
medicine the child slept without the rotation. Then 
a plentiful crop of acne developed, and the mother 
interrupted the medicine. The paroxysms returned. 
The medicine was repeated, but this time its effect 
was much less marked. The paroxysms were not in- 
terrupted, but they were diminished in intensity — did 



CASE OF NOCTURNAL ROTARY SPASM. 1 73 

not begin until twelve or one o'clock — on many nights 
were omitted. This diminution persisted even after 
the medicine was interrupted. 

The second peculiarity in our case which distin- 
guished it from the general type of the spasmus 
nutans was the peculiar position of the body, which 
seemed to be a necessary condition for the occurrence 
of the spasm. The forcible turning over to the right 
side, the curving of the body, with the convexity to 
the left, the bending downwards of the head, offered 
a close resemblance to the forced attitude assumed by 
animals after lesions of certain parts of the brain. 
Section of one lateral peduncle of the cerebellum, or 
unilateral section of the medulla, carried down as 
far as the level of the tuberculum acusticum, will 
each be followed by an assumption of this peculiar 
attitude. 

The convex curving of the body may be directed 
towards the wounded or the sound side. 

It is said to have been first observed by Magendie 
after the unilateral section of the medulla. But, as is 
vv^ell known, Magendie, and many other observers 
after him, from Serres and Flourens to Ferrier, have 
been able to produce, by section of a lateral peduncle 
of the cerebellum, rotatory movements of the head 
and trunk, which succeeded to this fixed attitude, and 
were directed from the healthy to the wounded side. 
The rotary movements observed in our case re- 
semble these in every respect, even in the fact that 
they are directed from the side towards which the 
body is concave, towards the side at which it is con- 
vex, thus the presumably morbid side. 

Such rotary movements are known also to follow 
section of the horizontal branch of the semicircular 



1/4 CASE OF NOCTURNAL ROTARY SPASM. 

canals on one side, as I have myself had an oppor- 
tunity to observe in pigeons. But were lesions in 
these two localities alone capable of producing forced 
rhythmical oscillations, the data from experiment 
would fail to explain all the circumstances of our case. 
For in it the movements began with a simple lateral 
jerking of the head, such as may be produced by 
faradic irritation of the sterno-cleido-mastoid muscle, 
and seemed therefore to depend exclusively on irrita- 
tion of the spinal-accessory nerve. At this stage of 
the affection it constituted a typical '' clonic acces- 
sorius convulsion." And the proximate seat of the 
irritation must have been in the nucleus of the nth 
nerve, situated in the medulla. Now Magendie, who 
has first described the rotary movements and the 
fixed position determined by unilateral section of the 
medulla, has established that the latter lesion will also 
determine movements of rotation of the head and 
trunk around the longitudinal axis of the body. Re- 
cently Curschmann has asserted, that section of the pe- 
duncle of the cerebellum never determines the move- 
ments, but only the forced attitude, if the section be 
made at a certain distance from the medulla, and in- 
fers that the peduncular lesion is only effective in 
virtue of a secondary influence upon the medulla. 
With this view Eckhard entirely agrees. 

However this may be, there is no question that 
unilateral lesion of the medulla will be followed by 
this peculiar phenomenon, and it is unnecessary, in the 
absence of personal experience, to adduce more au- 
thorities in proof of this. 

Clinically, the forced lateral position, and even the 
rotary movements, have been observed in cases of 
demonstrated cerebellar lesion, but only when this 



CASE OF NOCTURNAL ROTARY SPASM. 1 75 

involved the processus vermiformis (Nothnagel)/ 
According to Nothnagel, these symptoms have not 
yet been observed in connection with lesion of any 
other part of the brain ; not therefore with disease of 
the medulla. He admits, however, that they may 
occur in epileptic and hysterical conditions, and 
that the transitory assumption of a forced lateral 
position not unfrequently marks the onset of an epi- 
leptic attack. 

Under these circumstances the phenomenon would 
be referred to medullary disease, though of a so-called 
functional character. 

If now we suppose an irritation of the nucleus of 
the right spinal-accessory nerve as the starting-point 
of the morbid process, we may, from the clinical 
history, infer that this irritation has gradually ex- 
tended upwards along the right half of the medulla. 
By the time it reached the nucleus of the acoustic 
nerve, a territory would have become involved whose 
lesion gives rise to complete rotations of the head 
and also of the trunk. Irritation of the floor of the 
4th ventricle is moreover powerful in the production 
of nystagmus. This symptom, and that of increased 
oscillations, would then complicate the original affec- 
tion, as we have seen that they did. 

Further extension of the irritation would reach the 
upper extremity of the calamus scriptorius and the 
region lying between it and the corpora quadrigemina, 
which is considered to contain the principal vaso- 
motor centre ; hence the flushing of the face and 

^ The rolling of the head in acute hydrocephalus bears some resemblance 
to the rotary movements we are describing. But it might perhaps be possible 
to demonstrate that this symptom only occurred when, by distension of the 
aqueductus Sylvii, fluid had passed from the lateral to the fourth ventricle, and 
was exerting pressure on the medulla. 



176 CASE OF NOCTURNAL ROTARY SPASM. 

acceleration of the pulse which begin to coincide with 
the paroxysm. Whether the irritation was extended 
to the cerebellum, and whether during the paroxysm, 
hyperaemia really existed there and occasioned a rise 
of temperature perceptible at the occiput, we should 
perhaps hesitate to afhrm, but it seems not improba- 
ble. There is only one symptom which could possibly 
indicate an original cooperation of the cerebellum, in 
the place of the secondary participation we have 
supposed. I mean the defective articulation. But it 
is difficult to be certain that this is really a morbid 
condition. 

The observations on temperature were made pre- 
vious to the publication of Dr. Amidon's essay, and 
on that account the lateral frontal region of the head 
was not examined in respect to temperature. It 
would certainly be most interesting to ascertain 
whether automatic muscular contraction occurring in 
muscles during a prolonged clonic convulsion, would 
be followed by the same alterations of cranial tempera- 
ture as have been shown by Dr. Amidon, to follow 
voluntary contraction of the same muscles. 

The crooning cry, which has been the latest addi- 
tion to the symptomatology, must evidently be re- 
ferred to clonic spasm of the inferior laryngeal nerve, 
derived from the spinal-accessory filaments associated 
with the pneumogastric. 

In the absence of all other symptoms than those 
which have been described, and from the transitory 
and intermittent nature of the forced position and the 
rotary movements, we can hardly suppose an organic 
lesion to exist. We should rather infer a neurosis of 
an epileptiform nature, which, in its constant progress, 
is liable at any time to invade the pons, and occasion 



CASE OF NOCTURNAL ROTARY SPASM. 1 77 

an outbreak of true epileptic convulsions. Such an 
epileptiform character would explain the peculiarity 
of occurrence during sleep, period of repose for chorei- 
form affections, and with them for the ordinary spas- 
mus nutans. 

I should be very happy if any member of the Soci- 
ety may pursue, further than I have been able to do, 
the analysis of this case. 



V. 

THE PROPHYLAXIS OF INSANITY.' 

(Reprinted from the Archives of Medicine, vol. vi., No. 2, October, i88i.) 

A TERRIFIED popular Imagination still pictures in- 
sanity as some mysterious and monstrous incubus, 
coming from distant regions of darkness to crush out 
human reason. In reality, however, insanity means 
a complex multitude of morbid states, varying indefi- 
nitely in form and intensity, but all composed of ele- 
ments which preexist in health. This fact affords a 
basis for prophylaxis, for it indicates the possibility of 
detecting these elements, and, to a certain extent, of 
anticipating their morbid combinations. 

There are as many degrees in the soundness of 
men's minds as in the soundness of their digestions. 
Study of the organism of the family, some times in 
several generations, often serves to detect flaws in the 
individual organization otherwise too minute for notice. 
It is to the family organism that especially applies the 
doctrine of the blending of apparently opposite ele- 
ments, — as genius and insanity, — both springing from 
an unstable equilibrium of the nervous system. These 
elements sometimes, though rarely, blend in the same 
person. But far more frequently it is inheritance from 
the undeveloped side of an organization of genius 
which results in an organization of imbecility. 

^ A portion of a paper read before the American Social Science Association, 
at Saratoga, Wednesday, September 7, 1S81. 

178 



THE PROPHYLAXIS OF INSANITY. 1 79 

The original organization gives the physical substra- 
tum ; upon this the succession of psychic processes, 
which begin with the dawn of consciousness, builds up 
the mental individuality. Ideas, feelings, volitions, 
enter liberally into the structure of the mind, — are the 
constituent elements of which this has been built up. 
Permit me to quote the description given by the cele- 
brated Griesinger : 

" Self-consciousness, — the Ego," — he says, '* is an 
abstraction in which are contained, closely welded to- 
gether, a residue of all the sensibilities, thoughts, and 
volitions which the individual has ever experienced. 

*'. . . These are gradually aggregated into com- 
plex masses of conceptions, varying in density and 
resistance, according to the internal cohesion of their 
elements. . . . The character of the individual 
varies with their relative predominance ; their constant 
struggle with one another constitutes the internal con- 
flict which is essential to normal mental existence. 

'' . . . The development of insane delusions 
follows the same laws as that of healthy ideas. New 
sensibilities, volitions, and conceptions present them- 
selves to the preexisting conception-masses, are at first 
repelled by these, gradually penetrate them, and, if 
the cohesiveness of the latter be weak or w^eakened, 
assimilate to them until the Ego is transformed or 
completely falsified. In this process the previous com- 
position of the Ego is see7i to be of immense importance. 
A weak (loosely knit) nature will, much earlier than a 
strong one, be overborne by anomalous conceptions."' 

Thus, at any given moment, the mental organism 
consists not only of its physical substratum, but of 
that and of the long series of psychic processes which 

^ '■• Pathologic und Therapie der Psychischen Krankheiten," 1867. 



l80 THE PROPHYLAXIS OF INSANITY. 

have been built upon It. It is a fundamental law of all 
organized tissues, and most conspicuously illustrated 
In the brain, that function not only depends upon 
structure, but ends by modifying it. Hence, morbid 
modifications of psychic processes may be initiated 
either in them or in the physical substratum. This is 
equivalent to the previous assertion, that insanity may 
be determined either by a psychic or a somatic cause, 
but generally requires the concurrence of both. 

In the existing professional and popular reaction 
against the old puerilities of the exclusively moral 
theory of insanity, these facts are often overlooked or 
misunderstood. The question of prophylaxis has 
become narrowed down to the question of prophylaxis 
in marriage. This is not only much too narrow, and 
the social difficulties in the way very great, but the 
rules of practice have been by no means worked out, 
and many of those which have been suggested are 
erroneous or superficial. 

The fact that the previous constitution of the men- 
tal conception-masses modifies the process of their 
falsification under the influence of mental disease, 
should suggest an effort to so build up this constitu- 
tion that it may be fitted to resist strain. For the 
formation of the conception-masses is far from being 
a spontaneous or self-directed process. No ideas can 
enter the forming mind except from without, from 
communication with its fellows, or from the transfor- 
mation of sense impressions. It is therefore largely 
in our power to determine the nature of the ideas of 
any child who is thoroughly guarded from his cradle. 
Again, the will develops in the mould it makes for 
itself by successive volitions ; these may to a consid- 
erable extent be commanded or contrived. It follows 



THE PROPHYLAXIS OF INSANITY. l8l 

that, hand in hand with prophylactic treatment of the 
physical substratum of the inherited nervous organi- 
zation, should go strenuous educational prophylaxis 
of the psychic processes. But there is needed a far- 
sighted, comprehensive, minute education, which 
should begin with the dawn of consciousness, and 
extend, if possible, through life. It should have a 
detailed objective or reason for each step in the 
elementary lesions of the disease which menaces the 
person, or in the elementary defects of his menaced 
constitution. 

To assert that moral prophylaxis is useless because 
insanity is merely a symptom of physical disease, is to 
contradict the facts of the double nature and double 
origin of the psychoses which are admitted by the 
best authorities. Educational prophylaxis could only 
be expected to contribute one factor toward the solu- 
tion of the problem ; but it is one, and all the more 
worth considering, because at present it is so gener- 
ally neglected. 

A more plausible objection is, that the moral sub- 
stratum of minds predisposed to insanity is peculiarly 
perverted, so that they are insusceptible of education. 
That it is precisely this insusceptibility which especially 
manifests their predisposition. 

Finally, it may be alleged that the traits of char- 
acter which exist in a person before an attack of insan- 
ity, can offer no guide for treatment, because in the 
attack these are all reversed. 

This last objection is met by the answer that the 
prophylaxis of mental, as of somatic diseases, is to be 
directed, not to the symptoms of the malady, but to 
the constitutional defects which facilitate its invasion, 
and to the circumstances of the surrounding medium 



\S2 THE PROPHYLAXIS OF INSANITY. 

which become the occasioning cause. Thus, It is 
known that under a great weight of responsibility, a 
cheerful-tempered, but feeble-willed person, may break 
down Into melancholia. The prophylactic training 
should therefore be directed, not toward making such 
a person cheerful, but toward inuring him, by gradual 
practice, to bear responsibility. And so for other 
analogous cases. 

The ideal prophylaxis implies that In neuropathic 
families the entire life of each child, its physical and 
moral training, and every detail of its social surround- 
ings, should be planned with a view to avert mental 
disease. According to the degree of predisposition, 
this is liable to occur spontaneously at ordinary physi- 
ological crises, as puberty, menstruation, pregnancy, 
parturition, lactation, the climacteric ; or only under 
the Influence of external causes. In the latter case, 
the far-sighted disposition of the social medium of a 
predisposed person may often avert an attack of in- 
sanity by averting the cause. 

It is evident that the far-sighted and self-controlled 
guardianship required should be entrusted to a person 
not sharing the family constitution ; to the parent 
who may be exempt, or, if both are affected, to a per- 
son who Is not a relative at all. For the present pur- 
pose, only a word is needed in regard to the main 
details of physical prophylaxis. 

They are : abundance of nitrogenous food ; daily 
cold bathing ; pure air ; daily exercise In it, especially 
by means of cultivation of the ground, the cardinal 
employment of the body and mind of neurotics. 

A fifth point of great Importance is rest ; equally 
so for an immediately threatened attack, and in the 
life-long management of susceptible persons. For 



THE PROPHYLAXIS OF INSANITY. 1 83 

them over-exhaustion and fatigue are always to be 
dreaded, and to these they are particularly prone, 
from the extremely deficient power of resistance of 
their nervous system. It is worth noticing that it is 
neuropathic families more than any others who are 
liable to neglect the foregoing precautions. 

For effective moral prophylaxis, it is desirable that 
a certain amount of information be popularly diffused, 
to facilitate the awakening of domestic solicitude, the 
recognition of incipient insanity, and of the slighter 
but significant marks of the insane temperament. 
This may prove as useful as it has already done in 
regard to scrofula, rhachitis, tuberculosis, and other 
constitutional diseases. 

Krafft-Ebing ranks severe and congenital hysteria 
with the psychic degenerations, and shows it to be the 
forerunner of much real insanity.' Knowledge of this 
fact might do much to check the capricious and vacil- 
lating treatment to which youthful hysterical patients 
are generally subjected. On the other hand, in the 
permanent prophylaxis for adult life, which must so 
largely be committed to the patient, it is extremely 
useful to be aware of the relative benignity of the very 
forms of insanity which usually excite the most alarm. 
Acute melancholia, mania, and primary dementia are 
classed with the functional disorders of psycho-neu- 
roses, tending, under favorable circumstances, to spon- 
taneous recovery. This knowledge might help to 
avert at least those distressing suicides which are com- 
mitted, not from insane impulses, but under the dread 
of impending insanity. They are far from proving 
that this has already set in, for it is really not irra- 

^ This statement is not made in regard to acquired hysteria, symptomatic of 
uterine or other diseases. 



1 84 THE PROPHYLAXIS OF INSANITY^ 

tional to choose death in preference to permanent de- 
mentia. 

The following traits are signalized as characteristic 
of the neuropathic constitution — constitution which 
affords the main physical and moral basis for the de- 
velopment of insanity. 

In neuropathic families the children early manifest 
a remarkable nervous excitability, with tendency to 
severe neurotic disorders at physiological crises, as 
convulsions during dentition, neuralgias at menstru- 
ation. The establishment of menstruation is often 
premature, often preceded and followed by profound 
chloro-anaemia. The cerebral functions are easily 
disturbed, slight physical disorders being attended 
by somnolence, delirium, hallucinations. The nervous 
system seems to be everywhere hyperaesthetic. Re- 
action to either pleasing or displeasing impressions 
is excessive ; there are abundant reflex neuralgias, 
vaso-motor irritations. Pallor, blushing, palpitations, 
prsecordial anxiety, are caused by trifling moral ex- 
citement, or by agents lowering the tone of the vaso- 
motor nerves, as heat or alcohol. 

The sexual instincts are precocious and often per- 
verted. The establishment of puberty is often the 
sign for the development of spinal irritation, hysteria, 
or epilepsy. 

The psychic characteristics correspond. The dis- 
position is strikingly irritable and touchy ; psychic pain 
arises for trifling cause ; at the least occasion the most 
vivid emotions are excited. The subjects of this tem- 
perament alternate rapidly from one extreme to the 
other ; their sympathies and antipathies are alike in- 
tense ; their entire life is passed between periods of 
exaltation and depression, leaving scarcely any room 
for healthy indifference. 



THE PROPHYLAXIS OF INSANITY. 1 85 

On the other hand, there is a remarkable inexcit- 
ability of ethical feeling. Vanity, egotism, and a 
jealous suspiciousness are common, and the temper is 
often violent. The mind is often obviously feeble, 
with few and monotonous ideas, and sluggish associa- 
tion of them. At other times ideas are readily excited, 
the imagination is active, even to the production of 
hallucinations ; but mental activity is ineffective be- 
cause of the rapidity with which it leads to ex- 
haustion. There is no time to complete any thing 
before the energies flag. The will is equally decep- 
tive in its apparent exuberance and real futility. Its 
capricious energy and innate weakness is a fit counter- 
part for the one-sided talent or even whimsical genius 
which often marks the intelligence.^ 

This disposition constitutes the moral substratum 
which, together with the physical constitution, affords 
the constitutional basis for psychic disease. In it two 
elements are conspicuous : a profound and often un- 
conscious egotism, resulting from the predominance of 
the instincts over the faculties for external relations; and 
a constant ineffectiveness in the maintenance of these 
latter relations, — in other words, abnormal weakness of 
the will. These elements reappear in insane diseases. 
Egotism is the nucleus of the exactions of hysteria ; and 
also determines the form of all delusions, which, wheth- 
er primary, or engendered from emotional insanity, in- 
variably centre on the depression or exaltation of self. 
The suspiciousness and violent temper so frequent in 
the neuropathic, develops easily into the technical delir- 
ium of persecution or of quarrelsomeness. The psychic 
hyperaesthesia common to several psychoses, but typi- 
cal of melancholia, depends, on the one hand, on the 

^ Abridged from Krafft-Ebing. 



1 86 THE PROPHYLAXIS OF INSANITY. 

same primitive egotism ; on the other hand, on the 
weakness of the will, on account of which the normal 
channel from feeling to action is blocked. Pent-up 
feeling is always hyperaesthetic ; psychic pain is the 
correlative of external ineffectiveness, even w^hen not 
directly caused by it. 

Diminished interest in external relations results in 
psychic anaesthesia, especially in regard to moral ap- 
preciations. This anaesthesia is again the direct 
correlative of the excess of instinctive and personal 
interests, and of the weakness of the will, which fails to 
enlarge the scope of the personality, as it is naturally 
destined to do. 

When the will is feeble, sluggish, inert, the tendency 
of the mind to sink under pressure, and especially 
under the weight of responsibility, is very great. 
" The fact of human freedom," says Griesinger, " is 
the fact of the conflict in consciousness of opposing 
ideas, and of the termination of the strife by the con- 
ception-mass representing the Ego, which assimilates 
part of the ideas, and represses the rest." Feeble 
natures cannot bear this conflict without excessive 
pain, to which, at last, they not unfrequently succumb. 
In melancholia, the consciousness of diminished will 
power is a prominent and most painful symptom of 
the morbid state. 

The feebleness of the will may be manifested, not 
by sluggishness, but by infinite caprice and incessant 
vacillations. This may reflect a torrent of incoherent 
ideas ; or it may represent so rapid a transformation 
of an idea into an impulse that the latter alone seems 
to exist. Here the channel from the internal to the 
external world is not obstructed ; its resistance, on the 
contrary, is abnormally diminished ; yet the volition is 



THE PROPHYLAXIS OF INSANITY. 1 87 

Still ineffective. Effective volitions demand distinct 
and correct ideas of the external medium upon which 
they are to be expended. But one of the most essen- 
tial elements of insanity, and of the constitution 
predisposing to it, is the diminution in the number, 
force, variety, and accuracy of the ideas held concern- 
ing the external world, and on the relations of the 
individual to it. This monotony of ideas Is some- 
times, before the attack, concealed behind desultory 
verbiage. Sometimes, during the immediate pro- 
dromata of an attack, it is temporarily replaced, even 
in feeble-minded people, by an unwonted vivacity and 
power. Completed delirium, however, is always mo- 
notonous. Correlated to the egotistic instinct, it always 
centres on the personality of the individual, which is 
outrageously oppressed, or illimitably exalted. The 
ideas are few ; their associations sluggish ; memory and 
attention are weakened even to extinction. 

A deficient power of attention is generally a marked 
characteristic of the neuropathic state ; it lies at the 
basis of the irritable impatience, which is so frequent 
in It. This leads to the formation of loosely knit 
conception-masses, ready to assimilate anomalous no- 
tions. The mind is naturally credulous ; unapt for 
criticism. It offers less resistance than another to the 
invasion of false ideas. 

Thus the three great elements In the moral substra- 
tum of a person predisposed to Insanity, are : the ego- 
tistical predominance of the instincts over the faculties 
of reflection and external relation ; the ineffectiveness 
of the will, even when this is impulsive or violent ; the 
inaptitude for Ideas, resulting in their poverty and im- 
perfect combination. The whole nature Is shrunken 
upon itself ; there Is not enough vital turgescence to 



1 88 THE PROPHYLAXIS OF INSANITY. 

expand it to its normal circumference and to the points 
of contact of this with the external world. 

The cardinal point in the management of such na- 
tures is, therefore, the expansion of their shrunken 
individuality. This is to be effected by means of a 
strenuous educational system, directed at once toward 
the repression of the egotistic instincts, the enrich- 
ment and systematization of the ideas, and, through 
multiplication of acts and external relations, the ener- 
gizing of the feeble will. 

The scope of the method will be made clearer by 
some examples. Thus : grief is an efficient moral 
cause of insanity. That it does not more often ren- 
der people insane, is indeed a remarkable proof of the 
resources of the healthy human organism. However 
various the occasions for grief, yet in so far as these 
all imply personal loss, the principle of their influence 
is always the same. 

The mind becomes so concentrated on the thought 
of this loss, that the latter acquires the ascendancy of 
a fixed idea. Apart from physical disease, the inability 
of diversion is great, in proportion to the habitual 
poverty and monotony of ideas ; to the fewness of re- 
lations with the external world ; to the preponderance 
of habitual interest in matters relating to self ; to the 
inertness of the will, unable by vigorous action to ex- 
pend externally irritations of psychic pain. 

Similarly, when disappointment or humiliations, 
great or small, real or fancied, are the cause, or 
injuries, or the suspicion of injuries, the power of the 
predisposition and of the occasioning cause being 
constantly in inverse relation to each other, we reach a 
grade of exaggerated hysteria or hypochondria, where 
the egotistic instincts become able of themselves to 
generate melancholy, irritability, and delusions. 



THE PROPHYLAXIS OF INSANITY. 1 89 

In another class of causations, shock plays a promi- 
nent part. Inability to resist shock is partly propor- 
tioned to poverty of ideas, which permit overwhelming 
surprises ; partly to habitually unrestrained emotion- 
ality ; partly to the passivity which prevents quick 
reaction. Analogous is the effect of strain, of exces- 
sive anxiety, of long-standing care and responsibilities. 
Healthy and justly proportioned indifference is essen- 
tial to healthy equilibrium ; an excess of sensibility 
over reflection or will power, predisposes to insanity 
under sufficient irritation. All experience shows that 
an excess of egotistic sensibility is far more dangerous 
than an excess of sympathy, the latter being indeed 
extremely rare in the neuropathic constitution. It 
may become a cause in non-constitutional insanity. 
Another line of causation is that in the direction of 
ideas, where the invasion of false ideas is facilitated 
by habits of credulity, superficial reasoning, loosely 
knit conception-masses. An unreflecting enthusiasm 
easily embraces exciting doctrines, as in the various 
religious or political manias, or is carried away by 
suggestions which covertly appeal to the egotistic 
instincts, flattering or alarming them, or submits to 
incongruous beliefs, as in the so-called partial insanity 
or monomania. 

Perhaps none of the details of an educational pro- 
phylaxis are foreign to the principles theoretically 
advocated for ordinary education. But in this they 
are applied, if at all, in a manner so lukewarm and 
vague as would render them useless for so grave a 
problem as the prophylaxis of insanity. To consider 
these principles in the order already enumerated : the 
repression of egotistic instincts demands effort in two 
directions. Negatively, these are to be atrophied by 



IQO THE PROPHYLAXIS OF INSANITY. 

a studied atmosphere of indifference to caprice, violent 
tempers, ridiculous pretensions, exorbitant exactions ; 
none of which are allowed to be gratified. In this 
permanent atmosphere, created by the mind controll- 
ing and guarding the child, he may learn to appreciate 
his insignificance relatively to the external world. 
Toward this and its interests he is secretly apathetic, 
except so far as they may be made subservient to his 
own vanity. The principle of justice, based on the 
simple fact of primitive equalities, must be profoundly 
in-wrought, by practical exercises, into the conscious- 
ness of the neurotic. He is naturally inclined to 
submit every thing to the test of his sympathies and 
antipathies ; and the cultivated habit of reference to 
simple justice instead, will save him from innumerable 
entanglements, perplexities, and agitations, most dan- 
gerous to his mental equilibrium. 

The multiplicity of human interests, the vastness 
and importance of the interests of the world, as com- 
pared with his own, may be impressed upon the child's 
imagination in many ways, if ingenuity be not lacking. 
The incidents, utilized or contrived, necessarily vary 
with the age of the child, but the same complex end 
is always to be held in view : restoration of the normal 
proportion between egotistic instincts and faculties of 
relation, and excitation of healthful ideas through 
healthful practical experiences and association with 
the fortunes of his fellows. Sometimes together with 
mental vivacity, sometimes with mental inertness, the 
mind of the neuropathic individual is apt to be really 
indifferent to intellectual relations, to knowledge for 
its own sake, to disinterested curiosity, the happiest 
appanage of a sound intelligence. Interested motives 
must be skilfully supplied, sufficiently to provide for 



THE PROPHYLAXIS OF INSANITY. I9I 

the acquisition of knowledge essential to the enrich- 
ment of ideas, yet with caution, lest vanity and amour 
propre be unduly stimulated. 

The acquisition of knowledge, the training in mor- 
als, the formation of habits of thought, must all be 
centred upon practical activities. It is the proper de- 
velopment of these which is to be relied upon to en- 
ergize the feeble will ; to accustom it to effectiveness 
by training to productive industry ; to broaden and 
deepen the channels from internal concepts to im- 
pulses ; to provide thus for the overflow of dangerous 
irritations ; to check the flightiness, frequent forerun- 
ner of insane impulse ; to widen the range of interests 
and of correlative ideas, and hence of resource against 
shock, vexation, and misfortune ; to moderate inordi- 
nate vanity by submitting its pretensions to practical 
tests ; to regulate moods by habits of daily labor ; and 
to enlarge the entire personality, for the future as well 
as the present, by insuring, from internal pressure, the 
creation of a permanent career. This latter element 
of prophylaxis might well save from insanity many of 
the " lazy and languishing young ladies " whom Mor- 
timer Granville complains of as filling private insane 
asylums. 

It is not enough to attempt to widen the range of 
ideas. In some directions, and unguarded, this proves 
simply disastrous to persons of innately feeble intelli- 
gence. They must be trained in the formation of 
practical concepts ; associated as much as possible 
with practical facts, with sense impressions, and with 
experiences in action. Clearness, definiteness of ideas, 
their frequent association with images, afford no in- 
considerable safeguard against morbid mental confu- 
sion. Similarly the careful training of the senses in 



192 THE PROPHYLAXIS OF INSANITY. 

various techniques contributes much toward the steady 
outward direction of nervous energies, which is needed 
to counteract the tendencies to internal concentration. 

In this connection gymnastic training has a mental 
as well as a physical influence. It would be difficult 
to prove that such training of the periphery of the 
nervous system could counteract the development of 
hallucinations, which are caused by central irritation 
of the sensory centres. But it certainly lies in the 
line of such counteraction. 

If it be important to fill the mind with concrete 
ideas, it is at least as important that these be correct, 
and not liable to be uprooted in later life. This lia- 
bility constitutes a real danger in the notions of pop- 
ular theology, which are so loosely allowed to be ac- 
quired even by guardians who do not believe in them. 
To persons predisposed to insanity, the uprooting of 
fundamental ideas can by no means be performed 
with impunity. It is important to train such persons 
early in a sound and simple philosophy, which shall 
provide a firm basis for thought and life without invit- 
ing to speculative thinking. 

Finally, since the object to be gained is firmness 
and strength for the mind in dealing with its own con- 
cepts, practical exercises in the elementary intellectual 
acts are extremely important. These are but feebly 
carried out in ordinary schools, because the object in 
view is not distinctly perceived or firmly grasped. 
The first signs of failing mental power are : loss of 
memory, of power of association of ideas, of summon- 
ing contrasting ideas into consciousness, of reprodu- 
cing or comparing or criticising them. It is indicated, 
therefore, to train the mind in advance to profound 
habituation with these various processes. Such train- 



THE PROPHYLAXIS OF INSANITY. I93 

ing It is true will avail nothing when physical lesions 
have begun to destroy the intellectual mechanisms. 
But it may avail much in the cases where the integrity 
of these first becomes impaired from obstruction of 
function and psychic disability. 

One other detail deserves notice, for it rarely re- 
ceives attention. In minds predisposed to insanity 
there is often, perhaps always, a marked deficiency of 
elasticity. An impression sinks and remains ; the mind 
cannot disengage itself nor recover its tone ; it cannot 
pass quickly enough into the contrasting mood. Now 
the capacity to do this is the natural provision against 
strain : it probably corresponds to a law of rhythmic 
action in the physical mechanisms of thought. This 
capacity should, therefore, be carefully cultivated by 
encouraging alternations of attention at the first sign 
of fatigue. The contrary practice of forcing an im- 
mature mind to continued attention while under the 
influence of fatigue, instead of teaching it how to 
quickly change, is the habit of commonplace educa- 
tion. Injurious to all, it is especially so to persons 
predisposed to depressing forms of insanity. It ex- 
hausts still further the elasticity in which they are 
naturally deficient. 

The management of the perverted instincts of neuro- 
pathic constitutions may, when these are advanced in 
deterioration, prove a hopeless task. At a less severe 
degree, however, many bad propensities may be held 
in check by a skilful combination of the methods of 
punishment, — emulation and distracted attention. 

One difBculty in guiding these cases generally lies 
in the fact that their pathological nature is not early 
recognized. Children are incessantly moralized, 
whose minds do not contain any conceptions of mor- 



194 THE PROPHYLAXIS OF INSANITY. 

als, and only an imperfect mechanism for ethical 
functions. According to the degree of imperfection, 
such persons must be dealt with as animals, who can 
certainly be trained into habitual lines of conduct, 
even though destitute of the corresponding abstract 
ideas. 

One morbid appetite calls for special mention, that, 
namely, for alcoholic liquors. This, like the others, 
is often manifested early in life, and, as known, is not 
only a symptom of a neuropathic constitution, but, 
when indulged, a potent occasional cause of insanity. 
The management of this appetite is a most difficult 
problem. It has been plausibly suggested that the 
permanent and moderate administration of alcohol in 
the form of beer, might, with other treatment, help to 
avert the development of the irresistible craving. 

Such are the abstract principles of a system of 
treatment, which, if seriously carried out, properly 
associated with physical treatment, and so arranged 
that every other consideration should be subordinated 
to the attainment of its ends, should prove of real 
value in helping to avert many cases of insanity. 



VI. 



(Reprinted from the Archives of Medicine, vol. vi., No. i, August, i88i.) 

" Antagonism between Medicines and between 
Remedies and Diseases." — Cartwright Lectures for 
Year 1880. By Roberts Bartholow, M.D., Profes- 
sor of Materia Medica and General Therapeutics in 
the Jefferson Medical College of Philadelphia, etc., 
etc. D. Appleton & Co. 1881. pp. 122. 

The Cartwright lectures have been inaugurated 
most auspiciously by Dr. Bartholow. He has com- 
pressed into a narrow space a brilliant summary of 
the facts at present known in regard to one of the 
most fascinating questions of modern medicine. The 
demonstration of a precise antagonism between the 
action of drugs, has a double bearing on the theory 
of therapeutics. On the one hand, new practical re- 
sources are placed at our disposition, not merely to 
meet the accidents of poisoning, but, as we may hope, 
to combat symptoms similar to such accidents, when 
they have arisen spontaneously in the course of dis- 
ease. But a further and a more purely philosophical 
interest attaches to the study of the toxic symptoms, 
for the reason that their exact (remote) cause is 
known, and known to be an agent within our grasp. 

The very existence of such a definite train of symp- 
toms proves that we are able by external agencies to 
modify, in a given direction, the processes of a living 

195 



196 ANTAGONISM BETWEEN MEDICINES 

organism. This fact is in formal opposition to the 
fundamental doctrine of Medical Nihilism, which 
says : '' It is absurd to attempt to modify anatomical 
conditions by means of drugs." In view of the pal- 
pable contradictions to this doctrine which the facts of 
toxicology afford, one of two conclusions must be 
admitted. Either the symptoms induced by poisons 
are independent of anatomical conditions ; or else by 
the administration of a drug, we are able to change 
the anatomical conditions of health to those charac- 
teristic of an artificial disease. It is true that the 
condition thus voluntarily induced are only similar to 
those of natural disease, and by no means identical 
with them. '' We can," observes one of the most 
eminent authorities on artificial pathology, '' imitate 
symptoms but not diseases. We can render an ani- 
mal diabetic or epileptic, but we cannot create dia- 
betes or epilepsy." ' Nevertheless, this imitation is 
already of the greatest importance. And when, in 
studying the effects of one poison we find that they 
can be combated by the appropriate use of another, 
and that this second poison can be shown to be 
capable of initiating a train of symptoms exactly the 
opposite in appearance to those which have been 
caused by the first, a horizon certainly opens before 
us of a rational therapeutics, destined to encroach 
more and more on the therapeutics of pure em- 
piricism. 

The hope of such a future is distinctly communi- 
cated by Dr. Bartholow, even in the title of his lec- 
tures. Consideration of the '' antagonism between 
medicines " is immediately followed by discussions 
on an analogous antagonism '' between remedies and 

^ Vulpian. Lecons sur les maladies de la moelle epiniere. 



AND BETWEEN REMEDIES AND DISEASES. I97 

diseases," and to this latter subject are devoted two 
out of the six lectures of the course. 

It is on the '' scientific application of the principle 
of antagonism to medical practice " that the author 
seems to rely, to reverse the severe judgment pro- 
nounced on materia medica by Bichat, in 1818. '' It 
is a collection of incoherent opinions,- — is, perhaps, of 
all the physiological sciences, that which most exhibits 
the contradictions of the human mind. In fact, it is 
not a science for a trained intellect ; it is a shapeless 
mass of inexact ideas, of observations often puerile, of 
imaginary remedies strangely conceived and fantasti- 
cally arranged. It is said that the practice of medi- 
cine is repulsive. I go further than this : it is, in re- 
spect to its principles taken from our materia medicas, 
impracticable for a sensible man." (Quoted, p. 13.) 

Piquant indeed is the contrast between the uncer- 
tainty thus pungently described, and the exquisite 
precisions which, according to our author, may even 
now be predicted of so many therapeutic manoeuvres. 
We would not deny Prof. Bartholow's energetic opti- 
mism. Optimism, even when exaggerated, often 
serves, like the flag of the color sergeant, to lead a 
substantial advance. But in estimating the resources 
at our disposal for the removal of disease, we think it 
is of great practical importance to bear in mind the 
(often unknown) tertium quid, which distinguishes 
morbid processes of spontaneous, i. e., internal origin, 
from those which have originated in external influ- 
ences, whether traumatic or toxic. The problem for 
somatic diseases is the same as for insanity : health 
failure at any one point of the organism very often, if 
not always, implies deviation of the entire organism 
from the norm. It is this general health failure, as we 



198 ANTAGONISM BETWEEN MEDICINES 

are inclined to believe, which is at least one cause of 
the frequent failure to allay spontaneous symptoms by 
remedies which have been successfully antagonistic to 
the same symptoms when artificially induced. 

Did we follow Dr. Bartholow literally, we might 
infer that the different success in the two cases really 
depended on an absence of anatomical lesion as a 
basis for toxic symptoms. We are told to select our 
therapeutical agents on the basis of '' physiological an- 
tagonism." And this " means simply a balance of op- 
posed actions on the same tissue. It does not induce 
a change of structure. The opposing agents counter- 
balancing each other, the functional disturbance sub- 
sides, and the normal equilibrium is restored." (P. 1 1.) 

But physiological actions are inconceivable except 
as the concomitant of the molecular changes in the 
elements in function. The difference between each 
molecular change and gross palpable lesions of struc- 
ture, is one of degree not of kind. An agent that 
causes arterial tension by relaxing the peripheric arte- 
rioles, determines a rearrangement of the molecules 
in their muscular coat. An antagonistic drug which 
should raise the tension by really acting on the same 
arterioles, must necessarily reverse the molecular ar- 
rangement effected by the first. The objective of the 
second drug is not the " opposing action of the first," 
but the tissue which has been modified by that. 

But there are further objections to Dr. Bartholow's 
formula. We think it can be shown, even from his 
own summary of facts, that '* opposed actions on the 
same tissue " never take place except in one direction. 
When a tissue or organ is paralyzed by any poison, 
it fails to respond to other poisons which ordinarily 
have a tendency to stimulate it. This failure is ob- 



AND BETWEEN REMEDIES AND DISEASES I99 

served whether the paralyzing agent be administered 
first, or when the stimulating agent is in full operation. 
In the latter case, the stimulating poison is effectually 
antagonized. It is on this account that, as Dr. Bar- 
tholow himself remarks, the list of antagonisms ef- 
fected by atropine is so large : it paralyzes so many 
" end-organs." Paralyzing the ciliary branches of the 
third nerve to the pupillary sphincter and to the ciliary 
muscle, atropine antagonizes all drugs which cause 
myosis, either by stimulating the third nerve, or by 
antagonizing the ciliary muscle or circular fibres of the 
iris.^ Thus, it antagonizes pilocarpine, eserine, mus- 
carine, and the initial action of morphine. In the later 
stages of morphine poisoning, where vaso-motor paraly- 
sis of the iridian blood-vessels increases the myosis by 
turgescence of the iris, the counteracting effect is aided 
by its influence on the circulation. Now, in all the above 
cases, the antagonism of atropine to the myotic drugs 
is not reversed. When the pupil has been dilated by 
atropine, it is admittedly difificult to counteract it by 
any antagonist. In the most famous and thoroughly 
discussed antagonism, that between morphine and 
atropine, Dr. Bartholow declares that the pupil offers 
no sure guide, and that the action of atropine pre- 
ponderates. Muscarine will not contract the pupil 
dilated by atropine. (See p. 63 of Lectures.) 

According to Bartholow the '' atropinized pupil re- 
sists the action of eserine." (P. 54.) If, however, as 
Galezowski declares, eserine discs will contract a pupil 

^ Dr. Bartholow admits, in several places, that atropine "stimulates the 
radiating fibres of the iris " ; but of this we know of no proof. The experi- 
ments upon the excised eye, we believe first performed by Brown-Sequard, 
only demonstrate that atropine acts on nerve terminations, and that the central 
communication of the third nerve is not essential. This is precisely analogous 
to its action on the terminal branches of the vagus, after section of the trunk. 



200 ANTAGONISM BETWEEN MEDICINES 

SO dilated, it would be by directly tetanizing the circu- 
lar fibres of the iris ; thus there would be no " opposed 
action " on the third nerve. 

Quite similar observations hold true of the heart. 
Here again the " antagonism " of atropine is extensive 
and conspicuous, because it paralyzes the terminal 
fibres of the vagus in the cardio-inhibitory ganglion. 
Thus it antagonizes, in Dr. Bartholow's sense, by 
'' opposed action on the same tissue," all the drugs 
which slacken the pulse by stimulating either the cen- 
tral or peripheral portion of the inhibitory apparatus. 
Thus, it is antagonistic to digitalis, to morphine in its 
early stages, to muscarine. But the experiment is 
classical in toxic experimentation, wherein the heart, 
arrested by muscarine, may be set to beating by 
atropine, while the atropinized heart altogether re- 
fuses to respond to muscarine. When morphine suc- 
ceeds in reducing the pulse accelerated by atropine 
(and this is admittedly difficult), it does so by diminish- 
ing the excitability of the excito-motor ganglia. Here 
again, therefore, there is not '' an opposed action on 
the same tissue," but" a similar, z. e,\ paralyzing action 
on a very different tissue. 

Similarly, atropine will arrest the salivation caused by 
physostigma or pilocarpine, for it paralyzes the chorda 
tympani. When this paralysis has once been effected, 
salivation is no longer possible. Chloral will moder- 
ate the convulsions caused by strychnine ; there is no 
proof that strychnine will avert the respiratory paraly- 
sis threatened by toxic doses of chloral. 

Dr. Bartholow admits this last fact with great sur- 
prise. We consider it rather as an illustration of a 
general law that we have already indicated, and which 
may be thus formulated : 



AND BETWEEN REMEDIES AND DISEASES. 201 

" The response of an organ to a physiological or 
toxic stimulus, may be prevented by paralyzing the 
organ. But paralysis of an organ cannot be antago- 
nized by stimuli addressed to the organ, since the 
paralysis implies that susceptibility to impressions has 
been lost. Cure of paralysis can only be obtained by 
elimination of the paralyzing effect. During the pro- 
cess of elimination, the effects of the paralysis may 
often be combated by stimulation of other organs 
remaining able to respond. This constitutes a net 
antagonism to the effects of the poison, often effectual, 
but always indirect." 

It is this form of antagonism which is to be inferred 
from the " physiological basis " described by Dr. Bar- 
tholow. Part of this basis is afforded by the mechan- 
isms which exist throughout the body for systemic 
alteration of functions, with consequent " restraint of 
activities within proper limits." 

"If there were not some antagonism to the spasm 
centre, every trifling peripheral irritation would pro- 
duce most extravagant reflex effects. . . . The move- 
ments of the vessels are regulated by a vaso-motor 
centre in the medulla. By the opposed action of the 
dilator and constrictor forces, the vascular tonus is 
maintained at the normal. A similar mechanism con- 
trols the cardiac movements ; there is a motor appa- 
ratus for carrying on the action of the heart, and a 
regulator apparatus for restraining the movements 
within proper limits. . . . If the arterioles suddenly 
dilate, the blood pressure as quickly falls, but danger 
to the circulation is prevented by an increased action 
of the heart. . . . Here opposing forces maintain 
their equilibrium." (P. 21.) 

The presumption is that artificial antagonism to a 



202 ANTAGONISM BETWEEN MEDICINES 

given process In an organ will be best effected by act- 
ing upon the apparatus which provides for physio- 
logical antagonism to the same process. 

If we apply this principle to some of Dr. Bartho- 
low's favorite illustrations of antagonism, we shall 
discover quite a different interpretation of them from 
that given in these lectures. For instance, atropine is 
said to '* stimulate respiration," because accelerated res- 
piration is a phenomenon induced by atropine. Hence 
atropine is considered a valuable antagonist to any 
poison threatening death by " respiratory paralysis." 

Now, it must be observed, in the first place, that each 
of these opposed terms is not simple, but extremely com- 
plex. The acceleration of the respiration may depend 
upon several circumstances, and so also its slackening ; 
and special inquiry is necessary before we can be as- 
sured in any given case, that these are exactly op- 
posed to each other. Analogy, at least, would sug- 
gest that atropine paralyzes the inhibiting respiratory 
centres,^ and that the respiratory movements are thus 
accelerated in the same way as the cardiac, when their 
inhibitory apparatus is paralyzed. In antagonizing 
morphine, the same succession of events presents itself 
for the respiration as for the heart at the beginning of 
morphine poisoning. The respiration may be slowed, 
because the increased intracranial pressure has stimu- 
lated the inhibitory centre of inspiration, as it has the 
roots of the vagus and of the motor oculi nerve. 
Then the paralyzing effect of atropine would be bene- 
ficially antagonistic. Later on, when the susceptibil- 
ity of the inspiratory centre itself is becoming be- 
numbed, it might be (according to our theory) indi- 

^ Described by Rosenthal, Bemerk. iib. d. Thatigkeit d. automatischen 
Nervencentren, etc. Erlangen, 1875. 



AND BETWEEN REMEDIES AND DISEASES. 203 

rectly aroused by more rapid capillary circulation both 
throughout the tissues and in the medulla itself. By 
accelerating the circulation, therefore, atropine brings 
to bear upon the inspiratory centre the normal blood- 
stimulus to which it is physiologically adapted to re- 
spond. The antagonism to the effect of the morphine 
would therefore be indirect. 

We would note, in passing, that the common asser- 
tion (which Dr. Bartholow endorses), that morphine 
induces carbonic acid narcosis, seems to us very inac- 
curate. The characteristic reaction of the inspiratory 
centre to an excess of carbonic acid in the blood is 
convulsion, which morphine does not cause in adults. 
We think it could be shown that the slackening of the 
respiratory movements coincides with, and follows, 
diminution of molecular respiration in the tissues. The 
phenomena are those of apnoea, not of asphyxia ; there 
is not an excess of carbonic acid irritating the inspira- 
tory centre, but a deficiency, and leaving it in abnor- 
mally long intervals of repose. Hence, might be sus- 
pected another mode of action of atropine, in antag- 
onizing morphine, viz., an acceleration of the circula- 
tion and tissue-change. But into speculations like 
these. Dr. Bartholow does not enter. His summary, 
however, contains many illustrations of the doctrine 
we maintain, namely, that effective antagonism is 
always either paralytic or indirect. Thus, having no 
direct control over the cardiac tetanus of angina pec- 
toris, we can yet relieve the attack by paralyzing the 
contracted arteries through inhalations of amyl nitrite. 
Failing to arrest uterine hemorrhage by astringents 
directly applied to the bleeding surface, we may effect 
our purpose with nux vomica, which " stimulates the 
cardiac and respiratory centres." 



204 ANTAGONISM BETWEEN MEDICINES. 

And SO on. The more examples we multiply, the 
less should we be ready to accept Dr. Bartholow's 
mutual antagonism by means of '' opposed actions In 
the same tissues"; the more Inclined to believe that 
the antagonistic Influence Is necessarily exerted upon 
different organs, or upon tissues In the same appa- 
ratus. 

We have selected for comment the topic that hap- 
pened to attract our attention. We leave to others 
the agreeable task of seeking food for other reflec- 
tions from these most suggestive lectures. 



VII. 

HYSTERICAL LOCOMOTOR ATAXIA. 
Reprinted from \h& Archives of Medicine ^ vol. ix., No. i, February, 1883.) 

Ellen R., an Irishwoman, aged thirty-five years, 
consulted me first in the spring of 1878. She was a 
widow, and had had one child fifteen years previous 
to the time of my seeing her. She stated that her 
father had been insane for twenty-five years, and dur- 
ing the time that the patient was under observation, 
a brother became also insane, and remained so. 

The patient, a cook by profession, was a woman of 
sufificiently robust build, who claimed to have been in 
good health, not only before, but for several years 
after, her confinement. During seven years, however, 
her health had been impaired. 

The first symptoms of ill-health pointed to uterine 
disturbance : leucorrhoea, to which the patient paid 
little attention ; and vesical tenesmus and pain at 
micturition, which often were quite distressing. Not 
until several years later did she experience any pain 
about the pelvic region ; and then it was moderate 
and inconstant. More frequently she suffered from 
pains in the thighs, and more especially from numb- 
ness in the same region. Menstruation was regular 
and painless, but too profuse. 

Nervous symptoms, however, of manifold character, 
soon appeared, and masked those of local significance. 

205 



206 HYSTERICAL LOCOMOTOR ATAXIA. 

The first onset of these consisted in an attack, which 
she described as a '' fright," coming on as she was 
about to take some medicine for the vesical tenesmus. 
Apparently there must have been a spasm of the 
oesophagus, for she fancied she was about to have 
hydrophobia. It was accompanied by vertigo, dif- 
fused numbness and prickling throughout the body, 
and a feeling as though she would fall forward. 
These symptoms passed away after a few hours, but 
the patient remained so weak that she was unable to 
walk for several months. During this period of idle- 
ness she was subject to fits of weeping without cause. 

It was three years later, and several months before 
she consulted me, that the disturbances of motility, 
which henceforth became so prominent, began. The 
patient first experienced difficulty in going up and 
down stairs ; then, in rising to her feet from a kneel- 
ing posture ; finally, her gait in walking became ex- 
tremely unsteady — she swayed from side to side as 
she progressed, and often tried to support herself by 
surrounding objects ; the numbness in the limbs in- 
creased, but there was no pain. 

It was for this difficulty of locomotion that the pa- 
tient consulted me. On the first, and somewhat 
hurried, visit, I found that the uterus was slightly 
enlarged — the sound passing to a depth of eight 
centimetres — and considerably prolapsed. I inserted 
a cup-and-stem pessary, and showed the patient how 
to adjust it. This instrument effected so great an im- 
provement in her power of locomotion and of rising 
from the ground, that she ceased to visit me, and 
further examination of her case was thus postponed. 

The improvement lasted two or three months, but 
then ceased ; the difficulty of walking returned and 



HYSTERICAL LOCOMOTOR ATAXIA, 207 

increased ; patient grew weak and was obliged to give 
up work. During the summer and fall of this year 
she entered successively three hospitals — the Homoeo- 
pathic, St. Luke's, and the Presbyterian. In both the 
latter a positive diagnosis was made of locomotor 
ataxia, — diagnosis subsequently defended with earnest- 
ness in a personal conversation I had an opportunity 
of holding with one of the physicians who made it. 
This fact is mentioned as showing the deceptive char- 
acter of the symptoms in question. 

I next saw Ellen R. in Jan., 1879, after an interval 
of six months. I found the difficulty of locomotion 
so much increased that the patient was obliged to use 
a cane in walking. The gait was uncertain and 
staggering ; the arm not employed with the cane, 
oscillating, the body being inclined forward. She 
would walk at first slowly, then hurriedly ; the foot 
was thrust incoherently forward in different directions 
and then brought suddenly down to the ground. It 
was this element of the gait which seemed most dis- 
tinctively ataxic. The uncertainty of gait was in- 
creased by closing the eyes, and the patient could 
then with difficulty maintain her equilibrium. In this 
position, however, she resisted efficiently, firm down- 
ward pressure upon the shoulders. Recumbent, all 
movements of the limbs could be executed ; the ataxia 
disappeared. This was an important difference from 
the symptoms of tabes dorsalis. 

At this date there was no disturbance of sensibility 
in the limbs — neither pain nor anaesthesia. There was, 
however, a sense of constriction in the abdomen, ex- 
tending toward the epigastrium, but not around the 
back. There was also complete absence of the patellar 
tendon reflex. One sensitive point existed in the 



2o8 HYSTERICAL LOCOMOTOR ATAXIA, 

cervical spine. Faradic contractility was intact. The 
patient was slightly deaf in the right ear, and com- 
plained of impairment of vision of right eye, where, 
indeed, the optic nerve was partly atrophied. This 
circumstance had been recognized in the hospitals, 
and considered confirmatory of the diagnosis of loco- 
motor ataxia. But there had been a mechanical in- 
jury to the eye, and closer examination showed that 
this was the cause of the impairment of vision. 

During the last six months the patient had had 
several attacks of dysphagia, such as had ushered in 
her entire illness, but much more severe. In addition, 
she had become subject to violent attacks of dyspnoea, 
with alarming sense of suffocation. The voice had 
become habitually affected ; words were uttered spas- 
modically, the patient frequently catching her breath 
while she spoke, and usually terminating her sentence 
in a whisper. 

The patient had abandoned the use of the pessary, 
because she had had pain from it. The uterus was 
somewhat prolapsed — though less so than formerly, — 
heavy, and congested. Much endocervicitis existed, 
and it was now observed that the cervix was lacerated. 

The patient was taken into the New York In- 
firmary, the endocervicitis treated with carbolic acid 
and glycerine, and prolonged galvanic applications 
made to the spine. Under this treatment, with rest 
and good food, she improved greatly. By the middle 
of March she was able to walk a considerable dis- 
tance. In April the pessary was reapplied, and fara- 
dization of the limbs was substituted for galvanization 
of the spine. In July the patient left the infirmary, 
and immediately began to feel worse. 

I saw her again in September, 1879. The ataxic 



HYSTERICAL LOCOMOTOR ATAXIA. 209 

gait had returned. In addition, the patient suffered 
from pains shooting across loins, then from hip to 
ankle, " as if it darted all through." The pains simu- 
lated the fulgurating pains of locomotor ataxia, but 
the " stabbing " pains, on whose diagnostic value 
Seguin has laid much stress, were absent. The 
patient had a cotton-wool feeling under the sole of 
the feet, principally the great toe. As before, the 
tendon reflex was entirely absent. 

I still, however, persisted in the diagnosis I had 
made, of hysterical ataxia, primarily induced by uterine 
disease ; and explained the relapse by the existence of 
the laceration of the cervix. This caused few or no 
symptoms while the patient was at rest, and while the 
endocervicitis was being treated ; but became an 
efficient cause of irritation when the patient resumed 
work, walking, standing, etc. 

Toward the end of October I operated on the 
cervix, with complete success ; at the end of two 
months the uterus was normal in size and weight, kept 
in position ; the cervix perfectly healthy. 

At this time the patient *' felt much steadier on her 
legs." The ataxia and shooting pains disappeared, 
though there was still some swaying of the body while 
the patient walked. Facility of going up and down 
stairs has greatly increased. 

Throughout the winter, the patient having returned 
to service, her health remained only passably good. 
She was weak ; suffered from pains In hips and legs ; 
occasional cramps or patches of rigidity on Inside of 
foot or outside of thigh. In March of 1880, patient 
began to suffer from twitching in left leg at night, 
and both limbs began to be markedly paretic. The 
paresis was manifest even in the recumbent position ; 



210 HYSTERICAL LOCOMOTOR ATAXIA. 

the limb was lifted or moved in a lateral direction, 
sluggishly and with a sense of great effort. 

The patient always felt worse in the morning ; at 
first could hardly move, but having been on foot some 
time, could stand or walk pretty well ; always improved 
by application of faradic current to limbs. After a 
few minutes' application, much stronger contractions 
were obtained with the same strength of current. 

As six months had now elapsed since the operation 
and the removal of all uterine lesion, I began, for the 
first time, to fear that after all some form of chronic 
sclerosis of the cord existed, more probably lateral 
than posterior. Several symptoms were, however, 
lacking, but the recent occurrence of '* cramps '* 
seemed to herald the development of the rigid con- 
tractures and of the tremors characteristic of lateral 
sclerosis. 

At this point the patient ceased attendance. She 
continued to grow worse ; could not get up and down 
stairs ; had shooting pains all over her body ; lost 
flesh and appetite, Finally, she went out West (in 
August, 1881), travelled a good deal, remaining in 
service in different places according as her health 
would allow ; had several attacks of chills and fever, 
and of " congestion of the liver." But in the midst of 
these febrile disorders, and perhaps because of them (?), 
the hysterical symptoms gradually subsided. In Sep- 
tember, 1882, she returned to New York and came to 
see me. I found her entirely free from all her former 
troubles, only a very slight swaying of the gait re- 
called the paresis and ataxia of former times ; she 
could go up and down stairs, rise from her knees, etc., 
without difficulty. 

Coincidently, the aphonia, dysphagia, and dyspnoea 



HYSTERICAL LOCOMOTOR ATAXIA. 211 

had disappeared ; the patient suffered from pains 
nowhere. 

The tendon reflex, however was still absent. 

The diagnosis in this case rested upon : 

I St. The marked modification of the symptoms de- 
termined by each modification of the uterine disease : 
in the first place by the use of the pessary ; in the 
second, by treatment of the endocervicitis ; in the 
third, by the operation on the lacerated cervix. 

2d. The fact that ataxia of the lower extremities 
preceded all modifications of the sensibility. In tabes 
dorsalls some degree of anaesthesia (Rosenthal) of 
stabbing, or of fulgurating, pains (Seguin), always 
precedes any marked ataxia. It is conceivable that 
an hysterical anaesthesia should have existed in the 
case of Ellen R., and thus increased the difficulties of 
diagnosis, but it did not. 

3d. The coincidence of paresis of the lower extremi- 
ties, with or indeed out of proportion to the ataxia, as 
shown by the difficulty of rising from the knees, of 
going up stairs, etc. 

4th. The absence of ataxic incoherence in the 
movements executed in a recumbent position. 

5th. The absence of pupillary phenomena, bilateral 
atrophy of the optic nerves, gastric attacks ; the 
presence of paroxysmal dysphagia and dyspnoea, both 
predominantly hysteric phenomena ; the limitation of 
constriction to the abdomen. 

The diagnosis was, however, particularly obscured 

by: 

1st. The existence at one time of pains a good deal 
resembling fulgurating pains. 

2d. Of plantar anaesthesia, cotton-wool feeling under 
sole of foot. This, however, did not appear till late 



212 HYSTERICAL LOCOMOTOR ATAXIA. 

in the disease, and on close examination, seemed to be 
limited to the great toe. 

3d. The persistent absence of patellar tendon reflex. 

4th. The recurrence of symptoms after removal of 
all peripheric irritation in the uterine system. 

5th. The appearance of localized cramps and tre- 
mors in different parts of the lower limbs. On the 
whole, however, the diagnosis could be and was made 
out ; and was confirmed by the result. But its diffi- 
culty is best shown by the fact that the contrary diag- 
nosis was made in two hospitals, by most competent 
physicians, who, however, only had the patient under 
observation during a short space of time. 

The mechanism of the production of such symptoms, 
by means of an irritation, starting from the pelvis, is 
certainly very obscure. We must infer that the cen- 
tripetal impressions arriving from the focus of irrita- 
tion are distributed, on the one hand, to the posterior 
roots in the columns of Burdach ; on the other hand, 
to the lateral columns of the cord, in such a way as to 
produce respectively ataxia and loss of tendon reflex, 
as sclerosis of these same parts would have done. 
Since the early affection of sensibility in tabes dorsalis 
has been associated with the debut of the process in 
the columns of Goll, the absence of any sensory dis- 
turbance in the early history of our case becomes all 
the more important in excluding this portion of the 
cord from even functional disease, and thus in dis- 
tinguishing the case from true locomotor ataxia. 

The loss of tendon reflex — instead of the exaggera- 
tion of it, so often seen in hysteria — implies an in- 
hibition of the motor impulses transmitted through 
the lateral columns, — the inhibition dependent on 
irritation of posterior nerve-roots from pelvic irrita- 



HYSTERICAL LOCOMOTOR ATAXIA. 21 3 

tions. The inhibition constitutes a functional imita- 
tion of the effect which may be elsewhere produced 
through destruction of these same columns in organic 
disease. The ataxia and paresis must be similarly ex- 
plained ; as also the attacks of muscular rigidity 
transiently observed. The discovery by Charcot of 
organic disease — sclerosis of the lateral columns — in 
a case of hysterical contraction persisting till death, 
indicates the extent of possible affection of this part 
of the cord in hysteria. 



INDEX. 



Albuminuria in hysteria, 52 

Alcoholism in neuropathic constitu- 
tion, 194 

Amenorrhea in hysteria, 54-59 

Anaesthesia, hysterical, 34 

Antagonism of, drugs, 195 ; by paral- 
ysis, 199 ; atropine with digitalis, 
morphine, muscarine, physostig- 
mine, pilocarpine, 200 ; chloral and 
strychnine, 200 ; formula for, 201 ; 
physiological, 201 ; by different 
organs, 202 ; always paralytic or 
indirect, 203 

Aphonia, 60 

B 

Battey's operation, 79 

Bichat on absurdities of therapeutics, 

197 
Broadbent on theory of language, 147 



Carbonic acid narcosis through mor- 
phine, 203 
Cerebral vibrations involved in speech, 

151 
Chloro-ansemia, deficient fixation of 

oxygen in, 22 
Choked disk, 90-93 ; experiments on, 

by Adamkiewicz, 93 
Conception masses in mind, 180 ; 

prophylaxis of, 181 ; loose knitting 

of, 189 
Conglomerate expressions in speech, 

the earliest, 155 ; dissolution of, in 

noun aphasia, 159 
Contracture, hysterical, compared 

with that of organic disease, 33 
Convulsions, hysterical, 31, 32 ; in 

brain tumor, 86, 87 
Cortical motor centres, hypothesis of 

Meynert, 4 

D 

Degeneration and hysteria, 63 
Diabetes in hysteria, a sign of medul- 
lary irritation, 51 
Diagnosis, of hysteria, 64 ; hysterical 



locomotor ataxia, 21 1 ; differential 
for brain tumors, 136 ; localized for 
tumors, cerebellum, 125 ; pons, 
125 ; peduncle, 126 ; cerebral cor- 
tex, 126 ; basal ganglia, 126 , cor- 
pora quadrigemina, 127 ; medulla, 
127 ; anterior fossa, 128 ; sella 
turcica, 128 ; middle fossa, 129 
posterior fossa, 129 
Diffused symptoms in brain tumors, 
82 ; without focal symptoms ; 94 



Ego, constitution of, 179 

Egotism, treatment of, 190 

Elasticity, mental, deficient, 193 ; de- 
ficiency treated, 193 

Electricity in hysterical pain, 36-39, 
76 

F 

Fatal case of hysteria, 48 
Fatigue, hysterical, cerebral symp- 
tom, 26, 27 
Focal svmptoms in brain tumors, 95, 

Forebrain always affected in hysteria, 

22 

Fusion of cerebral impressions to 
words, 149 

G 

Ganglionic cells, receiving and dis- 
charging centres, 6 
General treatment of hysteria, 77 
Gymnastics in prophylaxis of insanity, 
192 

H 

Headache in hysteria, 43 ; in brain 
tumor, 82-84 

Health lift in hysteria, 71-73 

Hearing, taste, and smell in brain 
tumor, 119 

Hysteria, fundamental condition of, 
I, 12 ; deficient storage of force in 
2 ; severe constitutional disease, 
64 ; deficient centrifugal nerve, im- 
pulses in, 4 ; congenital, a psychic 
degeneration, 183 



215 



2l6 



INDEX. 



Ideas, conflict of, i86 ; poverty of, 

Inhibition, nature of, 8 ; of motor and 
mental activities by sensory centres, 
9 ; mental, 12-16 

Insanity and hysteria, 63 



Language, disturbance of, with brain 

tumors, iig 
Latent areas, of cerebral cortex, 6 ; 

brain tumors, 130 
Lesions, complicating brain tumors. 

Locomotor ataxia, hysterical, 204- 
210 ; diagnosis of, 211 ; analysis of, 
212, 213 

M 

Massage and hydrotherapeutics, 78, 

79 

Maternal instinct checked in hysteria, 
18, 19 

Moral causes of insanity, 180 ; sub- 
stratum of insane predisposition, 
187 ; impressions in hysteria, 64-66 

I Motor, functions, stimulation of, as 
treatment of hysteria, 68-70 ; le- 

' sions in brain tumors, 97 

N 

Naming process, 146 
Nature of brain tumors, 134 
Neuralgias, 42 
Neurasthenia, 63 
Neuropathic constitution, 184 
Neuroses, medullary spinal, compared 

with hysteria, 23 
Nominalism and abstract ideas, 153 
Nouns and verbs, 156 



Opposite actions in same tissue, 198, 

^99. . 
Organization of words in brain, 157, 

Ovarian hypersesthesia, 53, 54 



Pains of hysteria, 36 ; are cerebral 
hallucinations, 40 ; compared with 
hallucinations of insanity, 40, 41, 

45 . . 
Paralysis in, hysteria, 23-26 ; brain 
tumor, 99 ; tumor cortex, 100-102; 
centrum ovale, 103 ; basal ganglia, 
104 ; peduncles, 105 ; corp. quad- 



rigemina, 106 ; cerebellum, 106 ; 
pons, 107-110 ; medulla, 11 1 

Pathological anatomy of brain tumors, 
136 

Physiological actions and molecular 
changes, 198 

Practical mental training, 191, 192 

Prophylaxis of insanity, theoretical 
objections to, 181 ; ideal, 182 ; phy- 
sical, 182 ; of hysteria, 65 

Psychic characteristics of hysteria, 
17, 118 ; changes in brain tumors, 
88, 89 

R 

Rotary spasm, case, 161-166 ; analy- 
sis, 172-175, 176 ; treatment, 172 

Rotations after experiments on brain, 
167 

S 

Salaam convulsion, 168 

Sensory, centres, predominance in hys- 
teria, 2 ; derangements of, 8 ; le 
sions in brain tumor, 112 

Shock causing hysteria, analogy with 
chorea, 20 ; insanity, 189 

Shrunken individuality, mode of ex- 
pansion, 188 

Skwortzkoff, theory of language, 148 

Sleep of hysterics, 27-29 

Spasm, of unstriped muscle, 59, 60 ; 
visual accommodation, 61, 62 

Speech, primitive development of, 
154 ; dissolution of, 154 

Suspensive hysteria, 21 

Symptomatology of brain tumors, 81, 
122 ; due to locality, 124 



Treatment hysteria by change of 
scene, 66 ; by stimulating motor 
functions, 68-70 ; brain tumors, 138 

Tremors and spasms in brain tumors, 

97 
Tuberculosis and hysteria, 63 
Tumors of brain, 82 

V 

Vaso-motor, irritation brain, re- 
searches of Anjel, 30 ; neuroses, 

51-59 
Vertigo in brain tumors, 84 
Visual, disturbance in brain tumors, 

114-118 ; hallucinations, 46 
Voluntary acts, development of, 5 
Vomiting in brain tumors, 85 

W 

Waldenburgh apparatus, 75 



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Knapp, and others. Svo ........... 75 

" Full of interesting cases. We cordially recommend it to the attention of our readers, * * * It reflects 
great credit on the authors." — London Lancet. 

LEFFERTS. Pharmacopceia for the Treatment of Diseases of the Larynx, 
Pharynx, and Nasal Passages. With Remarks on the Selection of Remedies, 
Choice of Instruments, and Methods of Making Local Applications. By George 
M. Lefferts, M.D. i6mo, cloth i 00 

" What is recommended in this work can be accepted as having been thoroughly tested." — Canadian 
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MACCORMAC. Surgical Operations. Part I. : Ligature of Arteries. A Short 
Description of the Surgical Anatomy and Llodes of Tying the Principal Vessels. 
Ninety-three illustrations. By Sir William MacCormac, Surgeon and Lecturer 
on Surgery, St. Thomas' Hospital, England. Cloth . . . . . . i 40 

MANN. A Manual of Prescription Writing. By Matthew D. Mann, M.D., 
Late Examiner in Materia Medica and Therapeutics in the College of Physicians 
and Surgeons, New York. Fourth edition. Revised, enlarged, and corrected 
according to the U. S. Pharmacopoeia cf i83o. i6mo, cloth . . . . i 00 
"An excellent little work, of value to the pharmacist as well as to the physician." — National Druggist 

Nov., 1885 

MARSHALL. Neurectasy, or Nerve-Stretching. For the Relief or Cure of 
Pain. The Bradshaw Lecture delivered at the Royal College of Surgeons, 
England, December, 1883. With an appendix, dated March, 1887. By John 
Marshall, F.R.S., LL.D. Illustrated by Victor A. H. Horsley, F.R.S. 
Cloth I 40 

MARSHALL AND MARSH. A Junior Course in Practical Zoology. By 

A. Milnes Marshall, M.D., Professor of Zoology in Owens College, England, 
and C. H. Hurst, Demonstrator of Zoology in Ovs^ens College, Eng. With 
48 wood-cuts, cloth, 8vo, . . . . . . . . . . . 3 5^ 

" Has special value for students of anatomy." — Prof. Henry F. Osrorn, Princeton College. 

MATTISON. The Treatment of Opium Addiction. By J. B. Mattison, M.D. 

8vo, cloth 50 

" It is a clear, concise treatment which will interest the profession." — Inter-Ocean^ Chicago. 

MEYNERT. Psychiatry: A Clinical Treatise on Diseases of the Fore- 
Brain, Based upon a Study of its Structure, Functions, and Nutri- 
tion. By Theodor Meynert, M.D., Professor of Nervous Diseases and Chief 
of the Psychiatrical Clinic in Vienna. Translated (under authority of the author) 
by B. Sachs, M.D, 8vo, cloth 2 75 

"We most earnestly urge our readers to put this work in their libraries as one that will prove indispensable." 
— Quarterly Journal of Inebriety ^ Jan., 1886. 

MORRIS. How We Treat Wounds To-Day. A Treatise on the Subject of 
Antiseptic Surgery which can be Understood by Beginners. By Robt. T. Morris, 
M.D. i6mo, cloth i 00 

OTIS. Practical Clinical Lessons on Syphilis and the Genito-Urinary Dis- 
eases. By Fessenden N. Otis, M.D., Clinical Professor of Genito-Urinary 
Diseases in College of Physicians and Surgeons, New York. Svo, cloth. Formerly 
$4.50; reduced to 2 00 

" The work is very thorough in every detail." — Medical Record. 

PARKER. Cancer: Its Nature and Etiolo^. With Tables of 397 Illustrated 

Cases. By WiLLiARD Parker, M.D. 8vo, cloth i 50 

" Will prove of value to all who are interested in cancer." — National Druggist^ Nov., 1885. 



Medical Publications of G. P. Putnam s Sons. 

ROBERTS. Lectures on Dietetics and Dyspepsia. By Sir William Roberts, 

M.D., F.R.S. Second edition, cloth I 00 

" We have read these letters with a singular pleasure, and feel that we have largely gained from their 
perusal. Every practitioner should carefully read them." — Edinburgh Medical Journal^ Nov., 1886. 

SEIFERT AND MULLER. Manual of Clinical Diagnosis. With 60 illus- 
trations. By Dr. Otto Seifert, Privatdocent in Wurzburg, and Dr. Friedrich 
MuLLER, Assistent der II. med. klinik in Berlin. Translated, with the author's 
permission, from the third revised and enlarged edition, by William Bucking- 
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Visiting Physician to the Union Protestant Infirmary of Baltimore ; Lecturer on 
Normal Histology in the University of Maryland, Baltimore. 8vo, cloth . . i 25 
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SEMPLE. The Diseases of Children. A Hand-Book for Practitioners and Stu- 
dents. By Armand Semple, M.D. Cloth i 75 

" The book is a very fair presentation of its subject * * * and trustworthy. It is clearly written and 
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STICKLER. The Adirondacks as a Health Resort. By Joseph W. Stickler, 

M.D. i6mo, cloth . . . . . . . . . . . . i 00 

STUDENTS' AIDS SERIES. Paper, 25 cents ; cloth, 50 cents. 

Aids to Medicine. — Part III. (Double Part). Diseases of the Brain and its Mem- 
branes, of the Nervous System, of the Spinal Cord, and of the Ear. By C. E. Armand 
Semple. 

Aids to Medicine. — Part IV. Treating of Fevers, Skin Diseases, Worms, etc. By 
C. E. Armand Semple. In preparation. 

Aids to Surgery. By George Brown, M.R.C.S. 

Aids to Gynaecology. By Alfred S. Gubb, L.R.C.P., M.R.C S. 

Aids to Obstetrics. (Double Part.) By Samuel Nall, B.A., M.R.C. P., London. 

UPSHUR. Disorders of Menstruation (Students' Manual of). A Practical 
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i6mo, cloth I 25 

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